Women in Substance Abuse Treatment:

Results from the Alcohol and Drug Services Study

(ADSS)

Thomas M. Brady
Olivia Silber Ashley

Editors

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration
Office of Applied Studies
 Acknowledgments

This report was prepared by the Office of Applied Studies (OAS), Substance Abuse and Mental Health Services
Administration (SAMHSA), RTI International (a trade name of Research Triangle Institute) of Research Triangle
Park, North Carolina, and Synectics for Management Decisions, Inc., of Arlington, Virginia, under Contract No.
283-99-9018. At SAMHSA, Thomas M. Brady co-edited the report, and Theodora Fine, Sharon Amatetti, Peter
Delany, and Al Woodward provided review comments. At RTI, Olivia Silber Ashley was co-editor, and Mary Ellen
Marsden was senior advisor. B. Kathleen Jordan, Kara Riehman, and Wendee M. Wechsberg provided review
comments. Also at RTI, Molly Aldridge, Catherine Aspden, Kyung-Hee Bae, Michael Bradshaw, Jessica Cance,
Larry Crum, Jennie L. Harris, Mindy Herman-Stahl, Amy Hernandez, Jennifer J. Kasten, Kellie M. Loomis, Alex
Orr, Barry Weaver, Nathan West, and Megan Williams provided research or writing assistance; Diane G. Caudill
produced the graphics; Catherine A. Boykin and Loraine G. Monroe assisted with the tables; Joyce Clay-Brooks,
Linda Fonville, and Judith Cannada provided document preparation support; Teresa F. Gurley and Pamela Couch
Prevatt readied files for the SAMHSA printer and Web site; and D.J. Bost, Richard S. Straw, K. Scott Chestnut,
Jason Guder, and Jeff Novey copyedited and proofread the report. At Synectics, Sameena Salvucci, Leigh A.
Henderson, Alisa Male, Albert Parker, and Lev S. Sverdlov provided statistical, research, and writing support. Final
report production was provided by Beatrice Rouse, Coleen Sanderson, and Jane Feldmann at SAMHSA.

Public Domain Notice

All material appearing in this report is in the public domain and may be reproduced or copied without permission
from SAMHSA. However, this publication may not be reproduced or distributed for a fee without the specific,
written authorization of the Office of Communications, SAMHSA, U.S. Department of Health and Human Services
(DHHS). Citation of the source is appreciated. Suggested citation:

Brady, T. M., & Ashley, O. S. (Eds.). (2005). Women in substance abuse treatment: Results from
the Alcohol and Drug Services Study (ADSS) (DHHS Publication No. SMA 04-3968, Analytic
Series A-26). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office
of Applied Studies.

Disclaimer
The statements contained in this report are solely those of the authors and do not necessarily reflect the views,
policies, or position of OAS, SAMHSA, or any other part of the DHHS, and no official endorsement of the authors’
views is intended or should be inferred.

Obtaining Additional Copies of Publication

Copies may be obtained, free of charge, from the National Clearinghouse for Alcohol and Drug Information
(NCADI), a service of SAMHSA:

National Clearinghouse for Alcohol and Drug Information

P.O. Box 2345, Rockville, MD 20847-2345
(301) 468-2600, 1-800-729-6686, TDD 1-800-487-4889

Electronic Access to Publication

http://www.samhsa.gov
http://www.oas.samhsa.gov

Originating Office
SAMHSA, OAS
1 Choke Cherry Road, Room 7-1044
Rockville, MD 20857

September 2005

ii
 Table of Contents

Chapter Page

List of Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi
List of Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Gender Differences Among Substance Abuse Treatment Clients . . . . . . . . . . . . . . . . . . . 5
Substance Use and Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Economic Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Gender Differences in Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Psychological Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Family and Partner Influences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Social Stigma and Discrimination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Implications for Retention in Substance Abuse Treatment . . . . . . . . . . . . . . . . . 12
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Alcohol and Drug Services Study (ADSS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Overview of Chapters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

2. Substance Abuse Treatment Programming for Women: A Literature Review . . . . . . . . 29

Comprehensive Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Historical Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Availability of Substance Abuse Treatment Programming for Women . . . . . . . . . . . . . 32
Effectiveness of Substance Abuse Treatment Programming for Women . . . . . . . . . . . . 33
Child Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Prenatal Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Women-Only Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Mental Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Use of Supplemental Education Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

3. Data and Methods Used in This Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Data Source . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
ADSS Phase I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
ADSS Phase II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
ADSS Phase III . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Analysis Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Measures and Definitions of Terms Used in This Report . . . . . . . . . . . . . . . . . . . . . . . . 48
Client Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Components of Substance Abuse Treatment Programming for Women . . . . . . . 48

iii
 Table of Contents (continued)
Chapter Page

Other Facility Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Retention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Statistical Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Analysis of Client Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Analysis of Facility Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Descriptive Analyses of Treatment Retention . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Logistic Regression Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Survival Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Limitations of the Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
ADSS Phase I Data Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
ADSS Phase II Data Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Limitations of the Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

4. Characteristics of Substance Abuse Treatment Clients . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

5. Characteristics of Substance Abuse Treatment Facilities Providing Treatment

Programming for Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Female Clients in Substance Abuse Treatment Facilities . . . . . . . . . . . . . . . . . . . . . . . . 67
Availability of Substance Abuse Treatment Programming for Women . . . . . . . . . . . . . 67
Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Special Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Comparisons between Women-Only and Mixed-Gender Facilities . . . . . . . . . . . . . . . . 69
Comparisons between Facilities with and without Child Care Services . . . . . . . . . . . . . 70
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

6. Retention in Substance Abuse Treatment: Gender and Substance Abuse Treatment

Programming for Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Descriptive Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Logistic Regression Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Survival Analysis Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

7. Conclusion and Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Availability and Effectiveness of Substance Abuse Treatment Programming for
Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Implications for Service Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Implications for Treatment Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Implications for Treatment Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

iv
 Table of Contents (continued)

Chapter Page

Gender Differences in Substance Abuse Treatment Client Characteristics . . . . . . . . . . . 92

Implications for Treatment of Specific Populations . . . . . . . . . . . . . . . . . . . . . . 92
Treatment Retention among Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Implications for Treatment Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Issues in Women's Substance Abuse Treatment Research . . . . . . . . . . . . . . . . . . . . . . . 93
Implications for Future Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

Appendix

Statistical Methods and Limitations of the Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

v
 List of Figures

Figure Page

1.1 Numbers of Substance Abuse Treatment Admissions, by Gender and Year: TEDS,
1992–2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

2.1 Percentages of Facilities Offering Special Programs for Women or Pregnant

Women, by Type of Care: N-SSATS, 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

4.1 Percentages of Substance Abuse Treatment Clients Having a Child/Children at

Admission, by Gender and Service Type: 1997–1999 . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

4.2 Percentages of Employment at Admission among Substance Abuse Treatment

Clients Discharged from Outpatient Nonmethadone Treatment, by Gender:
1997–1999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

4.3 Percentages of Primary Source of Payment for Treatment among Substance Abuse
Treatment Clients Discharged from Outpatient Nonmethadone Treatment, by
Gender: 1997–1999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

5.1 Percentages of Female Clients in Substance Abuse Treatment Facilities, by

Facility Type of Care: 1996–1997 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

6.1 Percentages of Reasons for Discharge among Substance Abuse Treatment Clients
Aged 18 or Older, by Gender: 1997–1999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

6.2 Average Length of Stay (LOS), in Days, of Substance Abuse Treatment Clients
Aged 18 or Older, by Facility Type of Care: 1997–1999 . . . . . . . . . . . . . . . . . . . . . . . . . 79

vi
 List of Tables

Table Page

1.1 Alcohol Use in Past Month among Persons Aged 12 or Older, by Gender:
Percentages, NSDUH, 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

1.2 Substance Dependence among Persons Aged 12 or Older, by Gender: Percentages,

NSDUH, 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

2.1 Percentages of Substance Abuse Treatment Facilities Offering Child Care or

Prenatal Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

2.2 Randomized Studies of the Effectiveness of Substance Abuse Treatment

Programming for Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

3.1 ADSS Phase I Facility Sample Sizes, by Facility Characteristics and Availability
of Substance Abuse Treatment Programming for Women: 1996–1997 . . . . . . . . . . . . . 47

3.2 ADSS Phase II Client Sample Sizes for All Substance Abuse Treatment Clients
Aged 13 or Older, by Gender and Service Type of Care: 1997–1999 . . . . . . . . . . . . . . . 49

4.1 Percentages of Clients with Different Characteristics Discharged from Substance

Abuse Treatment, by Treatment Service Type and Gender: 1997–1999 . . . . . . . . . . . . . 62

5.1 Percentages of Substance Abuse Treatment Facilities Offering Substance Abuse

Treatment Programming for Women, Overall and by Facility Type of Care:
1996–1997 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

5.2 National Facility Rates (NFRs) and Percentages for Selected Substance Abuse
Treatment Facility Characteristics, by Facility Clientele Composition: 1996–1997 . . . . 71

5.3 National Facility Rates (NFRs) and Percentages for Selected Substance Abuse
Treatment Facility Characteristics, by Availability of Child Care Services:
1996–1997 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

6.1 Completion of Planned Treatment among Substance Abuse Treatment Clients

Aged 18 or Older at Admission, by Gender and Facility Type of Care . . . . . . . . . . . . . . 79

6.2 Length of Stay (LOS), in Days, among Substance Abuse Treatment Clients Aged
18 or Older at Admission, by Gender and Facility Type of Care . . . . . . . . . . . . . . . . . . . 80

vii
 List of Tables (continued)

Table Page

6.3 Completion of Planned Treatment among Female Substance Abuse Treatment

Clients Aged 18 or Older at Admission, by Facility Clientele Composition and
Facility Type of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80

6.4 Length of Stay (LOS), in Days, among Female Substance Abuse Treatment
Clients Aged 18 or Older at Admission, by Facility Clientele Composition and
Facility Type of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

6.5 Completion of Planned Treatment among Female Substance Abuse Treatment

Clients Aged 18 or Older at Admission, by Availability of Child Care Services
and Facility Type of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

6.6 Length of Stay (LOS), in Days, among Female Substance Abuse Treatment
Clients Aged 18 or Older at Admission, by Availability of Child Care Services
and Facility Type of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

6.7 Adjusted Odds Ratios (ORs) of Completion of Planned Treatment among

Substance Abuse Treatment Clients Aged 18 or Older at Admission
Discharged from Nonhospital Residential Facilities, Outpatient
Nonmethadone Facilities, or Combination Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . 83

6.8 Adjusted Odds Ratios (ORs) of Completion of Planned Treatment among

Female Substance Abuse Treatment Clients Aged 18 or Older at Admission
Discharged from Nonhospital Residential Facilities, Outpatient
Nonmethadone Facilities, or Combination Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . 84

6.9 Adjusted Hazard Ratios (HRs) of Length of Stay (LOS) among Substance
Abuse Treatment Clients Aged 18 or Older at Admission Discharged from
Nonhospital Residential Facilities, Outpatient Nonmethadone Facilities, or
Combination Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

6.10 Adjusted Hazard Ratios (HRs) of Length of Stay (LOS) among Female
Substance Abuse Treatment Clients Aged 18 or Older at Admission
Discharged from Nonhospital Residential Facilities, Outpatient
Nonmethadone Facilities, or Combination Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . 86

viii
 Highlights
Gender is an important variable to consider in substance abuse treatment research. The
proportion of females among substance abuse treatment clients has increased over the past
decade, and female clients currently constitute about one third of the treatment population.
Reports have shown that female substance abusers experience a number of barriers to receiving
treatment, including child care responsibilities, stigmatization, and inability to pay for treatment.
Female substance abusers are more vulnerable than male substance abusers to some of the
physiological effects of substance use, and substance abuse among females is rooted more often
in psychosocial problems and traumatic life events. These important gender differences suggest
the need for specialized treatment programming for women.

Women in Substance Abuse Treatment: Results from the Alcohol and Drug Services
Study (ADSS) presents an in-depth analysis of substance abuse treatment clients and facilities,
with a special focus on women. First, an introduction provides a brief history of how gender has
been addressed in previous substance abuse treatment studies, along with an overview of current
data about gender differences. Next, a literature review summarizes current information about
substance abuse treatment programming for women. Then, results from analyses of data from a
nationally representative sample of substance abuse treatment facilities and treatment clients
from ADSS provide new insights into gender differences among substance abuse treatment
clients, the availability of substance abuse treatment programming for women, and the extent to
which women-focused services are associated with treatment retention. Finally, a discussion of
the findings suggests implications and future research.

The in-depth review of current data and research findings on substance abuse treatment
programming for women (Chapter 2) places special emphasis on evaluations of effectiveness of
such programming. Substance abuse treatment programming for women includes diverse
services provided by treatment facilities that aim to reduce the barriers women face to entering
and staying in treatment and to address the specific substance abuse–related problems of women.
Such treatment may include the following:

! ancillary services, such as child care or transportation services, intended to

increase female clients' access to substance abuse treatment;

! services intended to address the specific needs of women, such as prenatal care
and well-baby care; and

! admissions for women only, creating a unique treatment environment that is more
focused on women's issues than is mixed-gender treatment.

Substance abuse treatment programming for women, which is not available at all substance abuse
treatment facilities, may substantially improve how long female clients remain in treatment. Key
highlights from Chapter 2 include the following:

1
 ! The substance abuse treatment system has increasingly recognized the need for
programming for women during the last 35 years.

! Services offered may be available only to a limited number of clients.

! Substance abuse treatment programming specifically designed for women, such as

provision of child care services, prenatal care services, women-only treatment,
mental health services, and supplemental services and workshops addressing
women-focused topics, can be beneficial in improving treatment outcomes.
Improved outcomes include changes in substance use, mental health symptoms,
perinatal/birth outcomes, employment, self-reported health status, and HIV risk
reduction.

Subsequent chapters in this volume provide insight into the gender differences in
demographic characteristics of substance abuse treatment clients, the organizational
characteristics of facilities that offer women’s substance abuse treatment programming, and the
treatment facility and client correlates of treatment retention as measured by completion of
planned treatment and length of stay (LOS) in treatment. Data for these analyses are from 2,395
substance abuse treatment facilities and 5,005 treatment clients in ADSS, which was conducted
for the Substance Abuse and Mental Health Services Administration (SAMHSA), part of the
U.S. Department of Health and Human Services (DHHS). Key highlights of the analyses results
are provided below:

Characteristics of Substance Abuse Treatment Clients

! Females and males in substance abuse treatment were similar on a number of

demographic characteristics. However, at admission to treatment, female clients
were more likely than male clients to have children (Chapter 4).

! Among clients in outpatient nonmethadone treatment,

– female clients were less likely than male clients to be employed full-time
and more likely to be unemployed;

– Medicaid was more likely to be the primary source of payment for

treatment among female clients than among male clients; and

– female clients were more likely than male clients to be admitted for drug
abuse instead of alcohol abuse (Chapter 4).

! Nationally, about 32 percent of clients in substance abuse treatment were female,

although this percentage varied by type of care: 30 percent of clients in outpatient
nonmethadone facilities (the most common type of care), 39 percent of clients in
outpatient methadone, 36 percent in nonhospital residential facilities, and 28
percent in hospital inpatient facilities were female (Chapter 5).

2
Facilities That Offer Substance Abuse Treatment Programming for Women

! An estimated 13 percent of substance abuse treatment facilities offered child care

services, and 12 percent offered prenatal services. Of all substance abuse
treatment facilities, 6 percent served women only, 37 percent offered special
programs for women, and 19 percent offered special programs for pregnant
women (Chapter 5).

! The availability of substance abuse treatment programming for women varied by

type of care. A larger proportion of nonhospital residential facilities served
women only than did other types of facilities, and outpatient methadone facilities
were less likely than other types of facilities to offer child care services. Special
programs for women overall were more likely to be offered in nonhospital
residential or outpatient methadone facilities than in other types of care. Special
programs for pregnant women were more likely to be offered in outpatient
methadone facilities than in other types of facilities (Chapter 5).

! Compared with mixed-gender facilities, women-only facilities served higher

proportions of blacks and clients whose primary source of payment was public
payment other than Medicaid and Medicare. Women-only facilities also were
more likely to offer child care services, prenatal care services, transportation
services, and special programs for women than were mixed-gender facilities
(Chapter 5).

! Compared with facilities that did not offer child care services, a larger proportion
of female clients were served by facilities that offered child care services.
Facilities offering child care services also were more likely to offer prenatal care
services, transportation services, and special programs for women than were
facilities without child care (Chapter 5).

Treatment Retention

! The rate of treatment completion was lower for women than for men in
nonhospital residential or outpatient nonmethadone facilities. However, after
controlling for client and facility characteristics, gender was not associated with
completion of planned treatment (Chapter 6).

! Women averaged shorter stays in nonhospital residential treatment than men, but
the LOS was similar among women and men in other types of care. After
controlling for client and facility characteristics, gender was not associated with
LOS (Chapter 6).

! Among women, receiving treatment at women-only facilities or at facilities

offering child care services was not associated with completion of planned
treatment, after controlling for client and facility characteristics. However, women
who received treatment at women-only facilities or facilities offering child care

3
services stayed in treatment longer than women who received treatment in
mixed-gender facilities or facilities not offering child care services, after
controlling for client and facility characteristics (Chapter 6).

4
 Chapter 1. Introduction

Gender is an important variable to consider when designing and analyzing studies in all
areas and at all levels of biomedical and health-related research (Wizemann & Pardue, 2001).
Consideration of gender and dissemination of data regarding gender differences, or lack thereof,
has been recommended by the Institute of Medicine (IOM). Gender is especially important in
substance abuse treatment services research because the background characteristics, substance
abuse patterns, and personal histories of female substance users may differ from those of males.
As such, treatment programming designed specifically for women is needed to address not only
women’s substance abuse-related problems but also their special needs and barriers to treatment.
Although many service providers acknowledge and address gender differences among substance
abuse treatment clients, these differences and the programming that addresses them have not
been adequately studied. At the national, State, and local levels, policymakers and service
providers need new knowledge to understand how male and female substance abuse treatment
clients differ in terms of sociodemographic and substance use characteristics and retention in
treatment. Information about the availability and effectiveness of substance abuse treatment
programming for women can help guide public policy about how the treatment system should be
structured.

This report discusses the need for substance abuse treatment programming for women
and summarizes evidence about the effectiveness of such programming. The report compares
characteristics of male and female clients discharged from substance abuse treatment and
estimates the availability of substance abuse treatment programming targeting women's needs.
Finally, the report provides new information about the relationship between gender, substance
abuse treatment programming for women, and retention in treatment.

This chapter includes a brief history of how gender has been addressed or ignored in
sentinel substance abuse treatment research studies. The chapter examines current data about
gender differences in substance abuse treatment utilization, substance use epidemiology, social
context and etiology of substance use, barriers to receiving treatment, physiological
consequences of substance use, and retention in substance abuse treatment. In addition, a brief
introduction to the Alcohol and Drug Services Study (ADSS) is presented, followed by an
overview of the remaining chapters in this report.

Gender Differences Among Substance Abuse Treatment Clients

Early substance abuse treatment studies—including the Drug Abuse Reporting Program
(DARP) and the Treatment Outcome Prospective Study (TOPS)—did not fully analyze
male-female differences in substance abuse treatment data (Kandall, 1996; Sells, Demaree,
Simpson, & Joe, 1978; Simpson & Sells, 1982). Analyses of important outcome measures were
not reported by gender, and in some instances, female research subjects were excluded from
analyses. The National Treatment Improvement Evaluation Study (NTIES), conducted from 1993
to 1995, and the California Drug and Alcohol Treatment Assessment (CALDATA), conducted
from 1992 to 1994, analyzed treatment outcomes by gender and reported many similarities

5
among females and males (Gerstein & Johnson, 2000; Gerstein et al., 1994). Gender differences
among treatment clients also have been analyzed using data from the Drug Abuse Treatment
Outcome Study (DATOS) (Grella & Joshi, 1999; Wechsberg, Craddock, & Hubbard, 1998).

The proportion of substance abuse treatment clients who are female has increased
moderately over the past decade (Figure 1.1). In 2002, according to the Treatment Episode Data
Set (TEDS), about 30 percent (565,000) of admissions to substance abuse treatment facilities
were females, up from 28 percent in 1992 (Substance Abuse and Mental Health Services
Administration [SAMHSA], 2004).

Figure 1.1 Numbers of Substance Abuse Treatment Admissions, by Gender and Year:
TEDS, 1992–2002.
2000000

1800000

1600000

1400000

1200000

1000000
800000

600000

400000

200000

0
1993 1995 1997 1999 2001
1992 1994 1996 1998 2000 2002
Year

Males Females

Source: SAMHSA, Office of Applied Studies, Treatment Episode Data Set (TEDS, 1992–2002)

It is important to consider the proportion of female substance abuse treatment clients in

the context of gender differences in the epidemiology of substance use and dependence (e.g.,
Walter et al., 2003; Weiss, Kung, & Pearson, 2003). According to the National Survey on Drug
Use and Health (NSDUH, formerly the National Household Survey on Drug Abuse [NHSDA]),
the proportion of females to males engaging in binge alcohol use (having five or more drinks on
the same occasion on 5 or more days during the past 30 days) in 2003 was similar to the above
proportion of females to males in substance abuse treatment (Table 1.1; Office of Applied
Studies [OAS], 2004a). However, the proportion of females (7 percent) to males (10 percent)
engaging in past month illicit drug use was higher than the proportion of females to males in
substance abuse treatment. The rate of substance dependence on an illicit drug was even more
similar between females (1.5 percent) and males (2.2 percent) (Table 1.2; OAS, 2004a).
Furthermore, research has shown that women who used psychotropic drugs, such as sedatives or
tranquilizers, were significantly more likely than men to develop dependence on those drugs
(Kandel, Warner, & Kessler, 1998).

6
Table 1.1 Alcohol Use in Past Month among Persons Aged 12 or Older, by Gender:
Percentages, NSDUH, 2003

Gender Binge Alcohol Use 1 Heavy Alcohol Use 2 Any Illicit Drug Use 3

Male 30.9 10.4 10.0

Female 14.8 3.4 6.5

1
Binge Alcohol Use is defined as drinking five or more drinks on the same occasion (i.e., at the same time or
within a couple of hours of each other) on at least 1 day in the past 30 days.
2
Heavy Alcohol Use is defined as drinking five or more drinks on the same occasion on each of 5 or more days in
the past 30 days; all Heavy Alcohol Users are also Binge Alcohol Users.
3
Any Illicit Drug includes marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or any
prescription-type psychotherapeutic used nonmedically.

Source: SAMHSA Office of Applied Studies, National Survey on Drug Use and Health, 2003.

Table 1.2 Substance Dependence among Persons Aged 12 or Older, by Gender:

Percentages, NSDUH, 2003

Gender Alcohol Any Illicit Drug 1

Male 4.3 2.2

Female 2.2 1.5

Note: Dependence is based on the definition found in the 4th edition of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV).
1
Any Illicit Drug includes marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or any
prescription-type psychotherapeutic used nonmedically.

Source: SAMHSA Office of Applied Studies, National Survey on Drug Use and Health, 2003.

Rates of substance use among adolescents show fewer gender differences. For example,
in the 2003 NSDUH, among adolescents aged 12 to 17, an estimated 11.4 percent of boys and
11.1 percent of girls had used an illicit drug during the past month (OAS, 2004a). According to
the 2003 Monitoring the Future national survey, the rate of past year use of any illicit drug other
than marijuana was slightly higher for girls than for boys (Johnston, O'Malley, Bachman, &
Schulenberg, 2003). There was little male-female difference in 8th and 10th grades in rates of
past year use of LSD, cocaine, crack, heroin, Ritalin, Rohypnol, and GHB. Furthermore, rates of
past year inhalant, amphetamine, and tranquilizer use were slightly higher among females than
among males in 8th and 10th grades. While these rates of substance use among adolescent
females raise concerns about risks for substance abuse and addiction in adulthood, additional
complexities have been identified for women in relation to substance use, including substance
use during pregnancy, economic considerations, physiological differences from men, co-
occurring psychological problems, traumatic experiences, family and partner influences, social
stigma and discrimination, and barriers to retention in substance abuse treatment.

7
Substance Use and Pregnancy

Among females, rates of substance use and treatment among pregnant women are of
special concern (Ebrahim & Gfroerer, 2003). The 2002 TEDS estimated that 4 percent of females
admitted to treatment were known to be pregnant when admitted (SAMHSA, 2004). Compared
with nonpregnant female admissions aged 15 to 44, pregnant admissions of similar age entering
treatment were more likely to report cocaine/crack (22 percent vs. 17 percent),
amphetamine/methamphetamine (21 percent vs. 13 percent), or marijuana (17 percent vs. 13
percent) as their primary substance of abuse (OAS, 2004b). Among pregnant women responding
to the 2002 and 2003 NSDUHs, 10 percent reported alcohol use, 4 percent reported binge alcohol
use, and almost 1 percent reported heavy alcohol use in the month prior to the survey (OAS,
2004b). The 2000–2001 Pregnancy Risk Assessment Monitoring System (PRAMS) estimated
that the prevalence of alcohol use during pregnancy ranged from 3 percent to 10 percent (Phares
et al., 2004). Women aged 35 or older, non-Hispanic women, women with more than a high
school education, and women with higher incomes reported the highest prevalence of alcohol use
during pregnancy. The 1992 National Pregnancy and Health Survey found that 19 percent of
females used alcohol during pregnancy, and 5 percent of females used an illicit drug at least once
during pregnancy, including marijuana (3 percent), psychotherapeutic medication without a
prescription (2 percent), and cocaine (1 percent) (National Institute on Drug Abuse [NIDA],
1996). More recent data from the Maternal Life Study, which oversampled very low birthweight
infants, found that 35 percent of pregnant females at four study sites reported alcohol use and 8
percent reported marijuana use during pregnancy (Lester et al., 2001). Meconium toxicology
screens were positive for cocaine or opioids in 11 percent of infants screened.

In studies of substance abuse treatment among women, pregnancy and childbearing are
important events because they may represent barriers to seeking, receiving, or completing
treatment. Women with substance use disorders may avoid seeking treatment for fear of losing
custody of their children (Ayyagari, Boles, Johnson, & Kleber, 1999; DeAngelis, 1993;
Finkelstein, 1994; Grella, 1997), due to well-publicized cases of drug use during pregnancy
resulting in prosecutions for child abuse, delivery of drugs to a minor, and other charges
(Associated Press, 2003; Chavkin, Breitbart, Elman, & Wise, 1998; Paltrow, 1992, 1998). For
example, 14 states consider substance use during pregnancy to be child abuse under civil child-
welfare statutes, and 9 states require health care professionals to report suspected prenatal
substance abuse (Figdor & Kaeser, 2005).

Women in treatment are more likely to be responsible for the care of children, to have
more children living in their homes, and to be more concerned about issues related to children
than men (Brady, Grice, Dustan, & Randall, 1993; Wechsberg et al., 1998; Wong, Badger,
Sigmon, & Higgins, 2002). Responsibility for children, coupled with little access to child care
services, is one of the most significant and most frequently cited barriers among females who
seek treatment (Allen, 1995; Copeland, 1997; Grella, 1997; Kaltenbach & Finnegan, 1998; van
Olphen & Freudenberg, 2004), and women with substance use disorders often perceive that many
substance abuse treatment programs fail to provide such services (Nelson-Zlupko, Dore,
Kauffman, & Kaltenbach., 1996). Referrals for substance abuse treatment programs in the past
often have neglected to accommodate the needs of low-income women with children, such as by
providing child care and transportation (Johnson & Meckstroth, 1998).

8
Economic Considerations

In addition to legal consequences and logistical difficulties, pregnant and parenting

women may experience economic consequences from treatment seeking. Recent studies have
estimated that between 5 and 35 percent of women receiving Temporary Aid to Needy Families
(TANF) have a substance abuse problem that can impede their ability to work (Klein & Zahnd,
1997). The 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA)
required TANF recipients to work 20 hours per week or to be engaged in job training or job
readiness activities. If appropriate substance abuse treatment is not received, substance abusing
women are unlikely to find or maintain employment, and their ability to provide care for their
children is diminished. Substance abuse treatment participation could be considered an activity
counted toward work requirements, although not all States allow this. In February 2003, the
House of Representatives and a Senate committee passed bills to reauthorize TANF through
2008. The House legislation increased the work requirements to 40 hours per week (24 hours of
direct work activities and 16 hours of approved indirect work activities to be determined by the
individual States). In this legislation, substance abuse treatment is considered to be an allowable
direct work activity for up to 3 months in any 24-month period. The Senate committee expanded
on the House legislation and proposed allowing substance abuse treatment to count toward work
requirements for 6 months within a 2-year period, provided that during the second 3 months
treatment is combined with work or job-readiness activities. The full Senate has not yet ruled on
this legislation.

However, women identified as substance abusers may also have difficulty maintaining
eligibility for entitlement programs. Many States either currently screen or plan to implement
alcohol and other drug screening of TANF recipients, and some require urine drug testing
(Montoya & Atkinson, 2002). The use of urine drug testing within TANF programs is still
controversial and has been implemented as a means of sanctioning TANF recipients (Hammett,
Gaiter, & Crawford, 1998). In addition, follow-up on referral to treatment often is limited, with
many women identified as needing treatment never presenting to receive it (Klein & Zahnd,
1997). Thus, access to treatment may be limited for substance-using females receiving TANF.

Further contributing to economic difficulties is the fact that female substance abuse
treatment clients have lower educational attainment and rates of employment than their male
counterparts (Wong et al., 2002). In a study of DATOS data, a national study of more than
10,000 substance abuse treatment clients, women were found to be younger, less educated, and
less likely to be employed than men (Wechsberg et al., 1998). In a study of Los Angeles
substance abuse treatment clients, the average age for females was lower than that for males, and
39 percent of females had less than a high school education compared with 19 percent of males
(Hser, Huang, Teruya, & Anglin, 2003). In an Oregon and State of Washington study of health
maintenance organization (HMO) clients, women were younger than men entering treatment, had
lower incomes, were less well educated, and were less likely to be employed (Green, Polen,
Dickinson, Lynch, & Bennett, 2002). Furthermore, although a greater proportion of males than
females entering treatment have no health insurance, when insured, females are more likely to
have public insurance than private insurance (Wechsberg et al., 1998).

9
Gender Differences in Physiology

Compared with male substance abusers, female substance abusers may have more
physical problems, and females appear to be more vulnerable than males to the physiological
effects of substance use. For example, in a study of alcohol problems among trauma center
patients, women were significantly more likely than men to have liver disease (Gentilello et al.,
2000). Differences in the way women absorb, distribute, eliminate, and metabolize alcohol may
increase their vulnerability to alcohol-related problems (Mumenthaler, Taylor, O'Hara, &
Yesavage, 1999; Wasilow-Mueller & Erickson, 2001). The female liver appears to be more
sensitive to the toxic effect of chronic alcohol intake than the male liver (Colantoni et al., 2003;
Mandayam, Jamal & Morgan, 2004; Mann, Smart, & Govoni, 2003). Females develop alcoholic
liver disease (i.e., cirrhosis and hepatitis) after comparatively shorter periods and less intense
drinking than do males. Although males have higher rates of cirrhosis mortality than women,
proportionately, more alcohol-dependent females die from cirrhosis than do alcohol-dependent
males (Fuchs et al., 1995; Lieber, 1993; Mann et al., 2003; NIAAA, 1999). One of the reasons
for gender differences in alcoholic liver disease is that females achieve higher concentrations of
alcohol in the blood than males after drinking equivalent amounts of alcohol (Bradley, Badrinath,
Bush, Boyd-Wickizer, & Anawalt, 1998; Frezza et al., 1990; Redgrave, Swartz, & Romanoski,
2003). In a cohort study of over 13,000 men and women in Europe, for example, the relative risk
of developing alcohol-related liver disease was significantly higher among women than men for
any given level of alcohol intake (Becker et al., 1996). An additional reason for gender
differences in alcoholic liver disease is that the level of alcohol dehydrogenase, an enzyme
associated with alcohol metabolism, may be lower in females than in males (Baraona et al., 2001;
Thomasson, 1995). Estrogen has also been associated with alcohol-related liver disease
(Moshage, 2001; Yin et al., 2000).

Although one review reports that evidence of gender differences in alcohol-induced brain
damage remains inconclusive (Hommer, 2003), most studies suggest that females are more
susceptible than males to the adverse neurologic consequences of alcohol (NIAAA, 1999;
Prendergast, 2004; Wuethrich, 2001). In a study of alcoholic and nonalcoholic men and women's
brain volumes, for example, the significance of differences in gray and white matter volumes
between alcoholic and nonalcoholic men was of a smaller magnitude than the significance of the
differences between alcoholic and nonalcoholic women (Hommer, Momenan, Kaiser, &
Rawlings, 2001). Females may also be more susceptible than males to alcohol-related cardiac
problems (Blum, Nielsen, & Riggs, 1998; Piano, 2002), and women have shown different
mechanisms leading to a higher sensitivity to alcohol-induced heart damage (Fernandez-Sola &
Nicolas-Arfelis, 2002; Urbano-Marquez et al., 1995). In a study of alcoholic cardiomyopathy, the
prevalence of heart disease was similar in alcohol-dependent males and females, yet alcoholic
women reported a significantly lower daily dose of alcohol, a shorter duration of alcoholism, and
a lower total lifetime dose of alcohol consumption than did alcoholic men (Fernandez-Sola et al.,
1997).

These biological differences may be associated with the physical functioning and overall
health status of women. In a study that reviewed medical records and interviewed research
subjects over a 2-year period, females who abused or were dependent on alcohol reported poorer
physical functioning, poorer physical and mental health, and disproportionately more impairment

10
compared with their male counterparts (Grazier, 2001). One report has shown death rates among
female alcoholics to be much higher than those of male alcoholics (Walter et al., 2003).

Psychological Problems

In addition to various medical problems, women substance abusers are at increased risk
for psychological problems (Alvarez, Olson, Jason, Davis, & Ferrari, 2004; Brady & Randall,
1999; Chander & McCaul, 2003; Chatham, Hiller, Rowan-Szal, Joe, & Simpson, 1999;
Gentilello et al., 2000; Mann, Hintz, & Jung, 2004; OAS, 2004c; Phillips, Carpenter, & Nunes,
2004; Wechsberg et al., 1998; Zimmermann et al., 2004). Psychosocial antecedents more likely
to be associated with substance use by females than with that of males include comorbid
psychiatric disorders, such as depression, anxiety, bipolar affective disorder, phobias,
psychosexual disorders, eating disorders, or posttraumatic stress disorder (PTSD) (Boyd, 1993;
Brady, Dansky, Sonne, & Saladin, 1998; Denier, Thevos, Latham, & Randall, 1991; Fornari,
Kent, Kabo, & Goodman, 1994; Institute of Medicine [IOM], 1990; Mendelson et al., 1991;
Merikangas & Stevens, 1998; Najavits, Weiss, & Shaw, 1997; Nelson-Zlupko, Kauffman, &
Dore, 1995; Saxe & Wolfe, 1999). For example, an analysis of the relationship of age at first
substance use relative to the onset of affective and anxiety disorders found that the onset of
psychiatric disorders preceded the onset of substance use disorders more often in females than in
males (Kessler et al., 1997). In addition, substance-dependent females have been found to be
more likely to need help for emotional problems at a younger age and to have attempted suicide
than substance-dependent males (Haseltine, 2000). Unfortunately, females with co-occurring
substance abuse and psychiatric disorders face unique barriers to substance abuse treatment, such
as difficulty in obtaining a dual disorder assessment and diagnosis, social stigma attached to both
conditions, and insufficient knowledge and training among providers of health, mental health, or
substance abuse treatment services to manage coexisting disorders (Grella, 1996, 1997).

Trauma

Substance use by females is linked to traumatic events or stressors, including sexual and
physical assault or abuse, sudden physical illness, an accident, or disruption in family life (Grella,
1997; IOM, 1990; Kilpatrick, Acierno, Resnick, Saunders, & Best, 1997; Kilpatrick, Resnick,
Saunders, & Best, 1998; Martin, Beaumont & Kupper, 2003; Najavits et al., 1997). Females
often use alcohol or other drugs to self-medicate in an effort to cope with these traumatic events
(Miranda, Meyerson, Long, Marx, & Simpson, 2002; Teusch, 2001; Young, Boyd, & Hubbell,
2002). Women with substance use problems have been found to be significantly more likely than
men to exhibit recent physical, emotional, or sexual abuse (Gentilello et al., 2000), and female
substance abuse treatment clients report more problems related to physical and sexual abuse and
domestic violence victimization than males (Green et al., 2002; Wechsberg et al., 1998).
However, some therapeutic approaches, such as confrontational models often used in traditional
therapeutic communities, present a special barrier for female substance abusers (Copeland, 1997)
because they often “reenact” traumatic experiences and may engender feelings of distress and
powerlessness associated with such experiences.

11
Family and Partner Influences

Female substance abusers are more likely than their male counterparts to report greater
dysfunction in the family of origin (Chatham et al., 1999) and lack adequate role models for
parenting (Davis, 1990; Sheridan, 1995). Females often are referred to substance abuse treatment
through child protective services as a requirement for retaining or regaining custody of children
(Clark, 2001). Poor interactions with children can also be a significant source of stress that
interferes with female's treatment efforts (Davis, 1990; Greif & Drechsler, 1993). In addition,
female substance abusers are more likely than male substance abusers to enter into dependent
relationships dominated by their partner (Woodhouse, 1992), hindering their ability to perform
basic life skills, such as managing money and planning for the future. Substance-dependent
females are more likely than substance-dependent males to have substance-dependent spouses or
partners (Amaro & Hardy-Fanta, 1995; Blum et al., 1998; Henderson, Boyd, & Mieczkowski,
1994; Riehman, Iguchi, Zeller, & Morral, 2003; Tuten & Jones, 2003), who may not be
supportive of their seeking treatment. Thus, seeking treatment may create a serious problem for
the relationship (McCollum & Trepper, 1995). The partner often not only discourages the woman
from entering treatment but also may threaten violence or leave the relationship if the woman
seeks treatment (Amaro & Hardy-Fanta, 1995), and partner substance use and treatment behavior
have been found to be more strongly associated with treatment motivation for females than for
males (Riehman, Hser, & Zeller, 2000). In contrast, common reasons for males' entering
treatment are family pressure and spousal opposition to substance abuse (Grella & Joshi, 1999).

Social Stigma and Discrimination

Substance use among females is more highly stigmatized than among males (Grella &
Joshi, 1999), and social stigma, labeling, and guilt are significant barriers for females to
receiving treatment (Ayyagari et al., 1999; Copeland, 1997; Dvorchak, Grams, Tate, & Jason,
1995; Finkelstein, 1994; IOM, 1990; Nelson-Zlupko et al., 1995). Stigma and guilt may foster
denial of problems by females, creating a further barrier to treatment (Blume, 1997). In addition,
females in a variety of treatment settings have been found to be more likely than males to belong
to minority racial/ethnic groups (e.g., Hser et al., 2003). As such, women in substance abuse
treatment may have experienced racism and may harbor mistrust of the medical and substance
abuse treatment systems, which may compromise provider-patient relationships and hinder
treatment and recovery.

Implications for Retention in Substance Abuse Treatment

A number of studies have shown that males remain in substance abuse treatment longer
than females (Hser, Evans, Huang & Anglin, 2004; Mammo & Weinbaum, 1993; Petry & Bickel,
2000; Sayre et al., 2002; Simpson et al., 1997a; Simpson, Joe, & Brown, 1997b; Simpson, Joe, &
Rowan-Szal, 1997c), even after controlling for other factors (Arfken, Klein, di Menza, &
Schuster, 2001; McCaul, Svikis, & Moore, 2001) and regardless of type of care (Arfken et al.,
2001). However, relatively few data are available about retention among female substance abuse
treatment clients, and findings are not consistent. The Treatment Outcome Prospective Study
(TOPS) of clients in treatment during the early 1980s showed that gender differences in length of
stay varied by type of care; longer stays in treatment were found for females compared with

12
males in outpatient methadone treatment and outpatient drug-free treatment, but no differences
were found among females and males in residential treatment (Hubbard et al., 1989). Some
recent studies have reported no gender differences in retention after controlling for other factors
(Wickizer et al., 1994), including analyses of DATOS data among residential and outpatient
methadone types of care (Broome, Flynn, & Simpson, 1999; Joe, Simpson, & Broome, 1999),
and higher rates of retention have been found among females than males in nonmethadone
treatment, after controlling for other factors (Broome et al., 1999; Joe et al., 1999).

Other factors associated with retention include age, race/ethnicity, education, marital
status, partner’s drug use, presenting substance abuse problem at admission, severity of substance
abuse, age at first use, psychiatric symptom severity, referral source, type of care, and intensity or
level of service (Ashley, Sverdlov, & Brady, 2004; Broome et al., 1999; Green et al., 2002;
Grella, Anglin, Wugalter, Rawson, & Hasson, 1994; Grella, Joshi, & Hser, 2000; Haller, Miles,
& Dawson, 2002; Hser, Joshi, Maglione, Chou, & Anglin, 2001; Joe et al., 1999; Kelly,
Blacksin, & Mason, 2001; Knight, Logan, & Simpson, 2001; Lang & Belenko, 2000); Maglione,
Chao, & Anglin, 2000; McCaul et al., 2001; Mertens & Weisner, 2000; Nishimoto & Roberts,
2001; Rowan-Szal, Joe, & Simpson, 2000; Smith, North, & Fox, 1995; Strantz & Welch, 1995;
Tuten & Jones, 2003; Veach, Remley, Kippers, & Sorg, 2000; Wickizer et al., 1994; Williams &
Roberts, 1991). However, large, nationally representative studies are lacking and knowledge gaps
still exist about factors influencing retention in substance abuse treatment, particularly among
females.

This report includes analyses of retention among a nationally representative sample of

substance abuse treatment facilities serving male and female clients. Treatment retention is
measured in two ways in this study: (1) as the percentage of clients who successfully completed
treatment and (2) as mean length of stay (LOS) in treatment. Both measures are important
because they are associated with improved treatment outcomes, such as reduced drug use,
criminality, or unemployment (French, Zarkin, Hubbard, & Rachal,1993; Green, Polen, Lynch,
Dickinson, & Bennett, 2004; Hser et al., 2004; Hubbard, Craddock, Anderson, 2003; Hubbard,
Craddock, Flynn, Anderson, & Etheridge, 1997; Metsch, McCoy, Miller, McAnany, & Pereyra,
1999; Satre, Mertens, & Weisner, 2004; TOPPS-II Interstate Cooperative Study Group, 2004;
Wallace & Weeks, 2004; Zarkin, Dunlap, Bray, & Wechsberg, 2002). Longer stays in treatment
among pregnant substance abusers have been associated with improved pregnancy and neonatal
outcomes (Kissin, Svikis, Moylan, Haug, & Stitzer, 2004). In a drug treatment program for
pregnant and postpartum women in New York City, for example, LOS was associated with less
maternal drug use and greater mean birth weight and less intrauterine growth retardation among
infants (McMurtrie, Rosenberg, Kerker, Kan, & Graham, 1999).

Summary

Women and men with substance use disorders are different. Among clients who present
for substance abuse treatment services, women have more children living in their homes, are
often younger, have lower incomes, and are less likely to be employed than men. Factors such as
the heightened scrutiny of substance use during pregnancy, the lack of affordable child care, and
social stigma impact women more than men. There also appear to be different reasons for
initiating careers in substance use among men and women. Important differences also appear to

13
exist among adults in the adverse consequences of substance use, although most of the findings
of gender differences deal with alcohol use and alcoholism.

Gender differences in social and psychological characteristics have important

implications for substance abuse treatment retention for females, although some important
studies show conflicting findings about the association between gender and retention. Females
have unique treatment needs in contrast to males, and gender-specific approaches to substance
abuse treatment have been developed to address these needs.

Alcohol and Drug Services Study (ADSS)

This report utilizes data from the Alcohol and Drug Services Study (ADSS). ADSS was
conducted between 1996 and 1999 for the OAS and was designed to collect detailed information
on the characteristics of substance abuse treatment facilities and their clients and to study the
relationships among facility characteristics, treatment services, and clients in treatment (OAS,
2003). The ADSS sample was selected using a multistaged, stratified design, with selection of
2,395 facilities in Phase I, selection of a subset of Phase I responding facilities, selection of client
discharge records in Phase II, and client follow-up in Phase III. Facilities in the sampling frame
were stratified by treatment type of care: hospital inpatient, nonhospital residential, outpatient
primarily alcohol, outpatient primarily methadone, other outpatient, and combined treatment
types (OAS, 2003).

Overview of Chapters

The chapters in this report review existing research and analyze ADSS data to provide
important new knowledge:

! Chapter 2, “Substance Abuse Treatment Programming for Women: A Literature

Review,” examines previous research on the availability and effectiveness of
substance abuse treatment programming for women.

! Chapter 3, “Data and Methods Used in This Report,” describes the ADSS data
source, measures of key study variables, and statistical methods.

! Chapter 4, “Characteristics of Substance Abuse Treatment Clients,” summarizes

the sociodemographic characteristics of female and male substance abuse
treatment clients.

! Chapter 5, “Characteristics of Substance Abuse Treatment Facilities Providing

Treatment Programming for Women,” estimates the prevalence of substance
abuse treatment programming for women.

! Chapter 6, “Retention in Substance Abuse Treatment: Gender and Substance

Abuse Treatment Programming for Women,” addresses the relationship between
gender and retention in treatment and between types of substance abuse treatment
programming for women and treatment retention among women.

14
! Chapter 7, “Conclusions and Implications,” summarizes the chief findings of this
report and discusses the implications of these findings with suggestions for future
research.

! The appendix, “Statistical Methods and Limitations of the Data,” discusses

generalizability of the study findings, suppression criteria for reporting results,
response rates, missing data, validity of data, and analytic methodology.

15
References

Allen, K. (1995). Barriers to treatment for addicted African-American women. Journal of the
National Medical Association, 87, 751-756.

Alvarez, J., Olson, B. D, Jason, L. A., Davis, M. I., & Ferrari, J. R. (2004). Heterogeneity among
Latinas and Latinos entering substance abuse treatment: Findings from a national database.
Journal of Substance Abuse Treatment, 26, 277-284.

Amaro, H., & Hardy-Fanta, C. (1995). Gender relations in addiction and recovery. Journal of
Psychoactive Drugs, 27, 325-337.

Arfken, C. L., Klein, C., di Menza, S., & Schuster, C. R. (2001). Gender differences in problem
severity at assessment and treatment retention. Journal of Substance Abuse Treatment, 20, 53-57.

Ashley, O. S., Sverdlov, L., & Brady, T. M. (2004). Length of stay among female clients in
substance abuse treatment. In C. L. Council (Ed.), Health services utilization by individuals with
substance abuse and mental disorders (pp. 107-132, DHHS Publication No. SMA 04-3949;
Analytic Series A-25). Rockville, MD: Substance Abuse and Mental Health Services
Administration, Office of Applied Studies. [Available at
http://www.oas.samhsa.gov/analytic.htm]

Associated Press. (2003, May 28). Court asked to review McKnight homicide by child abuse
case. Retrieved October 17, 2003, from http://charleston.net/stories/052803/sta_28crack.shtml,
which is no longer available. For a similar news story, see
http://advocatesforpregnantwomen.org/issues/sclaw2highcourt.htm.

Ayyagari, S., Boles, S., Johnson, P., & Kleber, H. (1999). Difficulties in recruiting pregnant
substance abusing women into treatment: Problems encountered during the Cocaine Alternative
Treatment Study. Abstract Book/Association for Health Services Research, 16, 80-81.

Baraona, E., Abittan, C. S., Dohmen, K., Moretti, M., Pozzato, G., Chayes, Z. W., Schaefer, C. &
Lieber, C. S. (2001). Gender differences in pharmacokinetics of alcohol. Alcoholism, Clinical
and Experimental Research, 25, 502-507.

Becker, U., Deis, A., Sorensen, T. I., Gronbaek, M., Borch-Johnsen, K., Muller, C. F., Schnohr,
P., & Jensen, G. (1996). Prediction of risk of liver disease by alcohol intake, sex, and age: A
prospective population study. Hepatology, 23, 1025-1029.

Blum, L. N., Nielsen, N. H., & Riggs, J. A. (1998). Alcoholism and alcohol abuse among
women: Report of the Council on Scientific Affairs, American Medical Association. Journal of
Women's Health, 7, 861-871.

Blume, S. B. (1997). Women and alcohol: Issues in social policy. In R. W. Wilsnack & S. C.
Wilsnack (Eds.), Gender and alcohol: Individual and social perspectives (pp. 462-489). New
Brunswick, NJ: Rutgers Center for Alcohol Studies.

16
Boyd, C. J. (1993). The antecedents of women's crack cocaine abuse: Family substance abuse,
sexual abuse, depression and illicit drug use. Journal of Substance Abuse Treatment, 10,
433-438.

Bradley, K. A., Badrinath, S., Bush, K., Boyd-Wickizer, J., & Anawalt, B. (1998). Medical risks
for women who drink alcohol. Journal of General Internal Medicine, 13, 627-639.

Brady, K. T., Dansky, B. S., Sonne, S. C., & Saladin, M. E. (1998). Posttraumatic stress disorder
and cocaine dependence: Order of onset. American Journal on Addictions, 7, 128-135.

Brady, K. T., Grice, D. E., Dustan, L., & Randall, C. (1993). Gender differences in substance use
disorders. American Journal of Psychiatry, 150, 1707-1711.

Brady, K. T., & Randall, C. L. (1999). Gender differences in substance use disorders. Psychiatric
Clinics of North America, 22, 241-252.

Broome, K. M., Flynn, P. M., & Simpson, D. D. (1999). Psychiatric comorbidity measures as
predictors of retention in drug abuse treatment programs. Health Services Research, 34, 791-806.

Chander, G., & McCaul, M. E. (2003). Co-occurring psychiatric disorders in women with
addictions. Obstetrics and Gynecology Clinics of North America, 30, 469-481.

Chatham, L. R., Hiller, M. L., Rowan-Szal, G. A. , Joe, G. W., & Simpson, D. D. (1999). Gender
differences at admission and follow-up in a sample of methadone maintenance clients. Substance
Use & Misuse, 34, 1137-1165.

Chavkin, W., Breitbart, V., Elman, D., & Wise, P. H. (1998). National survey of the states:
Policies and practices regarding drug-using pregnant women. American Journal of Public
Health, 88, 117-119. Erratum in 88, 438, and 88, 820. Comment in 88(1), 9-11.

Clark, H. W. (2001). Residential substance abuse treatment for pregnant and postpartum women
and their children: Treatment and policy implications. Child Welfare, 80, 179-198.

Colantoni, A., Idilman, R., De Maria, N., La Paglia, N., Belmonte, J., Wezeman, F., Emanuele,
N., Van Thiel, D. H., Kovacs, E. J., & Emanuele, M. A. (2003). Hepatic apoptosis and
proliferation in male and female rats fed alcohol: Role of cytokines. Alcoholism Clinical
Experimental Research, 27, 1184-1189.

Copeland, J. (1997). A qualitative study of barriers to formal treatment among women who
self-managed change in addictive behaviours. Journal of Substance Abuse Treatment, 14,
183-190.

Davis, S. K. (1990). Chemical dependency in women: A description of its effects and outcome
on adequate parenting. Journal of Substance Abuse Treatment, 7, 225-232.

17
DeAngelis, T. (1993). Better research, more help needed for pregnant addicts. APA Monitor,
24(9), 7-8.

Denier, C. A., Thevos, A. K., Latham, P. K., & Randall, C. L. (1991). Psychosocial and
psychopathology differences in hospitalized male and female cocaine abusers: A retrospective
chart review. Addictive Behaviors, 16, 489-496.

Dvorchak, P. A., Grams, G., Tate, L., & Jason, L. A. (1995). Pregnant and postpartum women in
recovery: Barriers to treatment and the role of Oxford House in the continuation of care.
Alcoholism Treatment Quarterly, 13, 97-107.

Ebrahim, S. H., & Gfroerer, J. (2003). Pregnancy-related substance use in the United States
during 1996-1998. Obstetetrics and Gynecology, 101, 374-379.

Fernandez-Sola, J., Estruch, R., Nicolas, J. M., Pare, J. C., Sacanella, E., Antunez, E., & Urbano-
Marquez, A. (1997). Comparison of alcoholic cardiomyopathy in women versus men. American
Journal of Cardiology, 80, 481-485.

Fernandez-Sola, J., & Nicolas-Arfelis, J. M. (2002). Gender differences in alcoholic cardiomyopathy.

Journal of Gender Specific Medicine, 5, 41-47.

Figdor, E., & Kaeser, L. (2005). Concerns mount over punitive approaches to substance abuse
among pregnant women. The Guttmacher Report on Public Policy, 1(5), 3-5.

Finkelstein, N. (1994). Treatment issues for alcohol- and drug-dependent pregnant and parenting
women. Health and Social Work, 19(1), 7-15.

Fornari, V., Kent, J., Kabo, L., & Goodman, B. (1994). Anorexia nervosa: “Thirty something.”
Journal of Substance Abuse Treatment, 11, 45-54.

French, M. T., Zarkin, G. A., Hubbard, R. L., & Rachal, J. V. (1993). The effects of time in drug
abuse treatment and employment on posttreatment drug use and criminal activity. American
Journal of Drug and Alcohol Abuse, 19, 19-33.

Frezza, M., di Padova, C., Pozzato, G., Terpin, M., Baraona, E., & Lieber, C. S. (1990). High
blood alcohol levels in women: The role of decreased gastric alcohol dehydrogenase activity and
first-pass metabolism. New England Journal of Medicine, 322, 95-99.

Fuchs, C. S., Stampfer, M. J., Colditz, G. A., Giovannucci, E. L., Manson, J. E., Kawachi, I.,
Hunter, D. J., Hankinson, S. E., Hennekens, C. H., & Rosner, B. (1995). Alcohol consumption
and mortality among women. New England Journal of Medicine, 332, 1245-1250. Erratum in
336, 523. Comments in ACP Journal Club, 1995, 123(3), 80-81, and New England Journal of
Medicine, 333, 1081-1082.

18
Gentilello, L. M., Rivara, F. P., Donovan, D. M., Villaveces, A., Daranciang, E., Dunn, C. W., &
Ries, R. R. (2000). Alcohol problems in women admitted to a level I trauma center: A gender-
based comparison. The Journal of Trauma, 48, 108-114.

Gerstein, D. R., & Johnson, R. A. (2000). Characteristics, services, and outcomes of treatment
for women. Journal of Psychopathology and Behavioral Assessment, 22, 325-338.

Gerstein, D. R., Johnson, R. A., Harwood, H. J., Fountain, D., Suter, N., & Malloy, K. (1994).
Evaluating recovery services: The California Drug and Alcohol Treatment Assessment
(CALDATA) (general report prepared for the State of California, Health and Welfare Agency],
Department of Alcohol and Drug Programs, under Contract No. 92-001100, Publication No.
ADP 94-629). Sacramento, CA: California Department of Alcohol and Drug Programs.

Grazier, K. L. (2001). Gender differences in the health status and services use: Consequences of
mental health disorders: A longitudinal study. Paper presented at Psychiatric Services for
Women: Symposium conducted at the meeting of the First World Congress on Women's Mental
Health, Berlin, Germany (D. Kohen & A. Wieck, chairs).

Green, C. A., Polen, M. R., Dickinson, D. M., Lynch, F. L., & Bennett, M. D. (2002). Gender
differences in predictors of initiation, retention, and completion in an HMO-based substance
abuse treatment program. Journal of Substance Abuse Treatment, 23, 285-295.

Green, C. A., Polen, M. R., Lynch, F. L., Dickinson, D. M., & Bennett, M.D. (2004). Gender
differences in outcomes in an HMO-based substance abuse treatment program. Journal of
Addictive Diseases, 23, 47-70.

Greif, G. L., & Drechsler, M. (1993). Common issues for parents in a methadone maintenance
group. Journal of Substance Abuse Treatment, 10, 339-343.

Grella, C. E. (1996). Background and overview of mental health and substance abuse treatment
systems: Meeting the needs of women who are pregnant or parenting. Journal of Psychoactive
Drugs, 28, 319-343.

Grella, C. E. (1997). Services for perinatal women with substance abuse and mental health
disorders: The unmet need. Journal of Psychoactive Drugs, 29, 67-78.

Grella, C. E., Anglin, M. D., Wugalter, S. E., Rawson, R., & Hasson, A. (1994). Reasons for
discharge from methadone maintenance for addicts at high risk of HIV infection or transmission.
Journal of Psychoactive Drugs, 26, 223-232.

Grella, C. E., & Joshi, V. (1999). Gender differences in drug treatment careers among clients in
the national Drug Abuse Treatment Outcome Study. American Journal of Drug and Alcohol
Abuse, 25, 385-406.

Grella, C. E., Joshi, V., & Hser, Y. I. (2000). Program variation in treatment outcomes among
women in residential drug treatment. Evaluation Review, 24, 364-383.

19
Haller, D. L., Miles, D. R., & Dawson, K. S. (2002). Psychopathology influences treatment
retention among drug-dependent women. Journal of Substance Abuse Treatment, 23, 431-436.

Hammett, T. M., Gaiter, J. L., & Crawford, C. (1998). Reaching seriously at-risk populations:
Health interventions in criminal justice settings. Health Education & Behavior, 25, 99-120.

Haseltine, F. P. (2000). Gender differences in addiction and recovery. Journal of Women's Health
& Gender-Based Medicine, 9, 579-583.

Henderson, D. J., Boyd, C., & Mieczkowski, T. (1994). Gender, relationships, and crack cocaine:
A content analysis. Research in Nursing & Health, 17, 265-272.

Hommer, D. W. (2003). Male and female sensitivity to alcohol-induced brain damage. Alcohol
Research & Health, 27, 181-185.

Hommer, D., Momenan, R., Kaiser, E., & Rawlings, R. (2001). Evidence for a gender-related
effect of alcoholism on brain volumes. American Journal of Psychiatry, 158, 198-204.

Hser, Y. I., Evans, E., Huang, D., & Anglin, D. M. (2004). Relationship between drug treatment
services, retention, and outcomes. Psychiatric Services, 55, 767-774.

Hser, Y. I., Huang, D., Teruya, C., & Anglin, D. M. (2003). Gender comparisons of drug abuse
treatment outcomes and predictors. Drug and Alcohol Dependence, 72, 255-264.

Hser, Y., Joshi, V., Maglione, M., Chou, C., & Anglin, M. D. (2001). Effects of program and
patient characteristics on retention of drug treatment patients. Evaluation and Program Planning,
24, 331–341.

Hubbard, R. L., Craddock, S. G, & Anderson, J. (2003). Overview of 5-year followup outcomes
in the drug abuse treatment outcome studies (DATOS). Journal of Substance Abuse Treatment,
25, 125-134.

Hubbard, R. L., Craddock, S. G., Flynn, P. M., Anderson, J., & Etheridge, R. M. (1997).
Overview of 1-year follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS).
Psychology of Addictive Behaviors, 11, 261-278.

Hubbard, R. L., Marsden, M. E., Rachal, J. V., Harwood, H. J., Cavanaugh, E. R., & Ginzburg,
H. M. (1989). Drug abuse treatment: A national study of effectiveness. Chapel Hill, NC:
University of North Carolina Press.

Institute of Medicine, Committee of the Institute of Medicine, Division of Mental Health and
Behavioral Medicine. (1990). Broadening the base of treatment for alcohol problems.
Washington, DC: National Academy Press. [Available at http://www.nap.edu/catalog/1341.html]

Joe, G. W., Simpson, D. D., & Broome, K. M. (1999). Retention and patient engagement models
for different treatment modalities in DATOS. Drug and Alcohol Dependence, 57, 113-125.

20
Johnson, A., & Meckstroth, A. (1998, June 22). Ancillary services to support welfare to work:
Substance abuse. Retrieved November 5, 2004, from
http://aspe.os.dhhs.gov/hsp/isp/ancillary/front.htm

Johnston, L. D., O'Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2003). Monitoring the
Future national survey results on drug use, 1975-2003: Volume 1, Secondary school students.
(NIH Publication Number 04-5507). Bethesda, MD: National Institute of Drug Abuse.

Kaltenbach, K., & Finnegan, L. (1998). Prevention and treatment issues for pregnant
cocaine-dependent women and their infants. Annals of the New York Academy of Sciences, 846,
329-334.

Kandall, S. R. (1996). Substance and shadow: Women and addiction in the United States.
Cambridge, MA: Harvard University Press.

Kandel, D. B., Warner, L. A., & Kessler, R. C. (1998). The epidemiology of substance use and
dependence among women. In C. L. Wetherington & A. B. Roman (Eds.), Drug addiction
research and the health of women (pp. 105-130, NIH Publication No. 98-4290). Rockville, MD:
National Institute on Drug Abuse. [Available as a PDF within the full document
(http://www.nida.nih.gov/WHGD/DARHW-Download2.html) at
http://www.nida.nih.gov/PDF/DARHW/105-130_Kandel.pdf]

Kelly, P. J., Blacksin, B., & Mason, E. (2001). Factors affecting substance abuse treatment
completion for women. Issues in Mental Health Nursing, 22, 287-304.

Kessler, R. C., Crum, R. M., Warner, L. A., Nelson, C. B., Schulenberg, J., & Anthony, J. C.
(1997). Lifetime co-occurrence of DSM-III-R alcohol abuse and dependence with other
psychiatric disorders in the National Comorbidity Survey. Archives of General Psychiatry, 54,
313-321.

Kilpatrick, D. G., Acierno, R., Resnick, H. S., Saunders, B. E., & Best, C. L. (1997). A 2-year
longitudinal analysis of the relationships between violent assault and substance use in women.
Journal of Consulting and Clinical Psychology, 65, 834-847.

Kilpatrick, D. G., Resnick, H. S., Saunders, B. E., & Best, C. L. (1998). Victimization,
posttraumatic stress disorder, and substance use and abuse among women. In C. L. Wetherington
& A. B. Roman (Eds.), Drug addiction research and the health of women (pp. 285-307, NIH
Publication No. 98-4290). Rockville, MD: National Institute on Drug Abuse. [Available as a
PDF within the full document (http://www.nida.nih.gov/WHGD/DARHW-Download2.html) at
http://www.nida.nih.gov/PDF/DARHW/285-308_Kilpatrick.pdf]

Kissin, W. B., Svikis, D. S., Moylan, P., Haug, N. A., & Stitzer, M. L. (2004). Identifying
pregnant women at risk for early attrition from substance abuse treatment. Journal of Substance
Abuse Treatment, 27, 31-38.

21
Klein, D., & Zahnd, E. (1997). Perspectives of pregnant substance-using women: Findings from
the California Perinatal Needs Assessment. Journal of Psychoactive Drugs, 29, 55-66.

Knight, D. K., Logan, S. M., & Simpson, D. D. (2001). Predictors of program completion for
women in residential substance abuse treatment. American Journal of Drug and Alcohol Abuse,
27, 1-18.

Lang, M. A., & Belenko, S. (2000). Predicting retention in a residential drug treatment
alternative to prison program. Journal of Substance Abuse Treatment, 19, 145-160.

Langeland, W., & Hartgers, C. (1988). Child sexual and physical abuse and alcoholism: A
review. Journal on Studies of Alcohol, 59, 336-348.

Lester, B. M., ElSohly, M., Wright, L. L., Smeriglio, V. L., Verter, J., Bauer, C. R., Shankaran,
S., Bada, H. S., Walls, H. H., Huestis, M. A., Finnegan, L. P., & Maza, P. L. (2001). The
Maternal Lifestyle Study: Drug use by meconium toxicology and maternal self-report. Pediatrics,
107, 309-317.

Lieber, C. S. (1993). Women and alcohol: Gender differences in metabolism and susceptibility.
In E. S. L. Gomberg & T. D. Nirenberg (Eds.), Women and substance abuse (pp. 1-17).
Norwood, NJ: Ablex.

Maglione, M., Chao, B., & Anglin, D. (2000). Residential treatment of methamphetamine users:
Correlates of drop-out from the California Alcohol and Drug Data System (CADDS), 1994-1997.
Addiction Research, 8, 65-79.

Mammo, A., & Weinbaum, D. F. (1993). Some factors that influence dropping out from
outpatient alcoholism treatment facilities. Journal of Studies on Alcohol, 54, 92-101.

Mandayam, S., Jamal, M. M. & Morgan, T. R. (2004). Epidemiology of alcoholic liver disease.
Seminars in Liver Disease, 24, 217-232.

Mann, K., Hintz, T., & Jung, M. (2004). Does psychiatric comorbidity in alcohol-dependent
patients affect treatment outcome? European Archives of Psychiatry and Clinical Neuroscience,
254, 172-181.

Mann, R. E., Smart, R. G., & Govoni, R. (2003). The epidemiology of alcoholic liver disease.
Alcoholism, Research and Health, 27, 209-219.

Martin, S. L., Beaumont, J. L., & Kupper, L. L. (2003). Substance use before and during
pregnancy: Links to intimate partner violence. American Journal of Drug and Alcohol Abuse, 29,
599-617.

McCaul, M. E., Svikis, D. S., & Moore, R. D. (2001). Predictors of outpatient treatment
retention: Patient versus substance use characteristics. Drug and Alcohol Dependence, 62, 9-17.

22
McCollum, E. E., & Trepper, T. S. (1995). “Little by little, pulling me through”—Women's
perceptions of successful drug treatment: A qualitative inquiry. Journal of Family
Psychotherapy, 6, 63-82.

McMurtrie, C., Rosenberg, K. D., Kerker, B. D., Kan J., & Graham, E. H. (1999). A unique drug
treatment program for pregnant and postpartum substance-using women in New York City:
Results of a pilot project, 1990-1995. American Journal of Drug and Alcohol Abuse, 25, 701-
713.

Mendelson, J. H., Weiss, R., Griffin, M., Mirin, S. M., Teoh, S. K., Mello, N. K., & Lex, B. W.
(1991). Some special considerations for treatment of drug abuse and dependence in women. In R.
W. Pickens, C. G. Leukefeld , & C. R. Schuster (Eds.), Improving drug abuse treatment (pp.
313-327, DHHS Publication No. ADM 91-1754, NIDA Research Monograph 106). Rockville,
MD: National Institute on Drug Abuse. [Available as a PDF at
http://www.drugabuse.gov/pdf/monographs/download106.html]

Merikangas, K. R., & Stevens, D. E. (1998). Substance abuse among women: Familial factors
and comorbidity. In C. L. Wetherington & A. B. Roman (Eds.), Drug addiction research and the
health of women (pp. 245-269, NIH Publication No. 98-4290). Rockville, MD: National Institute
on Drug Abuse. [Available as a PDF within the full document
(http://www.nida.nih.gov/WHGD/DARHW-Download2.html) at
http://www.drugabuse.gov/PDF/DARHW/245-270_Merikangas.pdf]

Mertens, J. R., & Weisner, C. M. (2000). Predictors of substance abuse treatment retention
among women and men in an HMO. Alcoholism, Clinical and Experimental Research, 24,
1525-1533.

Metsch, L. R., McCoy, C. B., Miller, M., McAnany, H., & Pereyra, M. (1999). Moving
substance-abusing women from welfare to work. Journal of Public Health Policy, 20, 36-55.

Miranda, R., Meyerson, L. A., Long, P. J., Marx, B. P., & Simpson, S. M. (2002). Sexual assault
and alcohol use: Exploring the self-medication hypothesis. Violence and Victims, 17, 205-217.

Montoya, I. D., & Atkinson, J. S. (2002). A synthesis of welfare reform policy and its impact on
substances users. American Journal of Drug and Alcohol Abuse, 28, 133-146.

Moshage, H. (2001). Alcoholic liver disease: A matter of hormones? Journal of Hepatology,

35(1), 130-133.

Mumenthaler, M. S., Taylor, J. L., O'Hara, R., & Yesavage, J. A. (1999). Gender differences in
moderate drinking effects. Alcohol Research and Health, 23, 55-64

Najavits, L. M., Weiss, R. D., & Shaw, S. R. (1997). The link between substance abuse and
posttraumatic stress disorder in women. A research review. American Journal on Addictions, 6,
273-283.

23
National Institute on Alcohol Abuse and Alcoholism. (1999, December). Alcohol Alert No. 46:
Are women more vulnerable to alcohol's effects? Retrieved December 5, 2003, from
http://www.niaaa.nih.gov/publications/alalerts.htm

National Institute on Drug Abuse. (1996). National Pregnancy and Health Survey: Drug use
among women delivering livebirths: 1992 (NIH Publication No. 96-3819). Rockville, MD:
Author.

Nelson-Zlupko, L., Dore, M. M., Kauffman, E., & Kaltenbach, K. (1996). Women in recovery:
Their perceptions of treatment effectiveness. Journal of Substance Abuse Treatment, 13, 51-59.

Nelson-Zlupko, L., Kauffman, E., & Dore, M. M. (1995). Gender differences in drug addiction
and treatment: Implications for social work intervention with substance-abusing women. Social
Work, 40, 45-54.

Nishimoto, R. H., & Roberts, A. C. (2001). Coercion and drug treatment for postpartum women.
American Journal of Drug and Alcohol Abuse, 27, 161-181.

Office of Applied Studies. (1997). Substance use among women in the United States, 1997
(DHHS Publication No. SMA 97-3162, Analytic Series A-3). Rockville, MD: Substance Abuse
and Mental Health Services Administration.

Office of Applied Studies. (2003). Alcohol and Drug Services Study (ADSS): Methodology
report: Phases I, II, and III. Rockville, MD: Substance Abuse and Mental Health Services
Administration. [Available as a PDF at http://www.oas.samhsa.gov/adss.htm]

Office of Applied Studies. (2004a). Results from the 2003 National Survey on Drug Use and
Health: National Findings (DHHS Publication No. SMA 04–3964, NSDUH Series H-25).
Rockville, MD: Substance Abuse and Mental Health Services Administration.

Office of Applied Studies. (2004b, September 3). Pregnant women in substance abuse treatment,
2002. The DASIS Report. [Available at http://www.oas.samhsa.gov/facts.cfm and
http://www.oas.samhsa.gov/2k4/pregTX/pregTX.cfm]

Office of Applied Studies. (2004c, August 20). Women with Co-Occurring Serious Mental
Illness and a Substance Use Disorder. The NSDUH Report. [Available at
http://oas.samhsa.gov/2k4/femDual/femDual.htm]

Paltrow, L. M. (1992). Criminal prosecutions against pregnant women: National update and
overview. Retrieved October 17, 2003, from
http://www.advocatesforpregnantwomen.org/articles/1992stat.htm

Paltrow, L. M. (1998). Punishing women for their behavior during pregnancy: An approach that
undermines the health of women and children. In C. L. Wetherington & A. B. Roman (Eds.),
Drug addiction research and the health of women (pp. 467-502, NIH Publication No. 98-4290).
Rockville, MD: National Institute on Drug Abuse [Available as a PDF within the full document

24
(http://www.nida.nih.gov/WHGD/DARHW-Download2.html) at
http://www.nida.nih.gov/PDF/DARHW/467-502_Paltrow.pdf]

Petry, N. M., & Bickel, W. K. (2000). Gender differences in hostility of opioid-dependent

outpatients: Role in early treatment termination. Drug and Alcohol Dependence, 58, 27-33.

Phares, T. M., Morrow, B., Lansky, A., Barfield, W. D., Prince, C. B., Marchi, K. S., Braveman,
P. A., Williams, L. M., & Kinniburgh, B. (2004). Surveillance for disparities in maternal health-
related behaviors--Selected states, Pregnancy Risk Assessment Monitoring System (PRAMS),
2000-2001. MMWR Surveillance Summary, 53, 1-13.

Phillips, J., Carpenter, K. M., & Nunes, E. V. (2004). Suicide risk in depressed methadone-
maintained patients: associations with clinical and demographic characteristics. American
Journal on Addictions, 13, 327-332.

Piano, M. R. (2002). Alcoholic cardiomyopathy: Incidence, clinical characteristics, and

pathophysiology. Chest, 121, 1638-1650.

Prendergast, M. A. (2004). Do women possess a unique susceptibility to the neurotoxic effects of

alcohol? Journal of the American Medical Women's Association, 59, 225-227.

Redgrave, G. W., Swartz, K. L., & Romanoski, A. J. (2003). Alcohol misuse by women.
International Review of Psychiatry, 15, 256-268.

Riehman, K. S., Hser, Y.-I., & Zeller, M. (2000). Gender differences in how intimate partners
influence drug treatment motivation. Journal of Drug Issues, 30, 823-838.

Riehman, K. S., Iguchi, M. Y., Zeller, M., & Morral, A. R. (2003). The influence of partner drug
use and relationship power on treatment engagement. Drug and Alcohol Dependence, 70, 1-10.

Rowan-Szal, G. A., Joe, G. W., & Simpson, D. D. (2000). Treatment retention of crack and
cocaine users in a national sample of long term residential clients. Addiction Research, 8, 51-64.

Satre, D. D., Mertens, J. R., & Weisner, C. (2004). Gender differences in treatment outcomes for
alcohol dependence among older adults. Journal of Studies on Alcohol, 65, 638-642.

Saxe, G., & Wolfe, J. (1999). Gender and posttraumatic stress disorder. In P. A. Saigh & J. D.
Bremner (Eds.), Posttraumatic stress disorder: A comprehensive text (pp. 160-182). Boston,
MA: Allyn and Bacon.

Sayre, S. L., Schmitz, J. M., Stotts, A. L., Averill, P. M., Rhoades, H. M., & Grabowski, J. J.
(2002). Determining predictors of attrition in an outpatient substance abuse program. American
Journal of Drug and Alcohol Abuse, 28, 55-72.

25
Sells, S. B., Demaree, R. G., Simpson, D. D., & Joe, G. W. (1978). Evaluation of present
treatment modalities: Research with DARP admissions, 1969-1973. Annals of the New York
Academy of Sciences, 311, 270-280.

Sheridan, M. J. (1995). A proposed intergenerational model of substance abuse, family

functioning, and abuse/neglect. Child Abuse & Neglect, 19, 519-530.

Simpson, D. D., Joe, G. W., Broome, K. M., Hiller, M. L., Knight, K., & Rowan-Szal, G. A.
(1997a). Program diversity and treatment retention rates in the Drug Abuse Treatment Outcome
Study (DATOS). Psychology of Addictive Behaviors, 11, 279-293.

Simpson, D. D., Joe, G. W., & Brown, B. S. (1997b). Treatment retention and follow-up
outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive
Behaviors, 11, 294-307.

Simpson, D. D., Joe, G. W., & Rowan-Szal, G. A. (1997c). Drug abuse treatment retention and
process effects on follow-up outcomes. Drug and Alcohol Dependence, 47, 227-235.

Simpson, T. L., & Miller, W. R. (2002). Concomitance between childhood sexual and physical
abuse and substance use problems. A review. Clinical Psychology Review, 22, 27-77.

Simpson, D. D., & Sells, S. B. (1982). Effectiveness of treatment for drug abuse: An overview of
the DARP research program. Advances in Alcohol and Substance Abuse, 2, 7-29. [Available as a
PDF at http://www.ibr.tcu.edu/pubs/recent/Simpson-82-AASA.pdf]

Smith, E. M., North, C. S., & Fox, L. W. (1995). Eighteen-month follow-up data on a treatment
program for homeless substance abusing mothers. Journal of Addictive Diseases, 14, 57-72.

Strantz, I. H., & Welch, S. P. (1995). Postpartum women in outpatient drug abuse treatment:
Correlates of retention/completion. Journal of Psychoactive Drugs, 27, 357-373.

Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (2004).
Treatment Episode Data Set (TEDS): 1992-2002. National Admissions to Substance Abuse
Treatment Services, DASIS Series: S-23, DHHS Publication No. (SMA) 04-3965. Rockville,
MD.

Teusch, R. (2001). Substance abuse as a symptom of childhood sexual abuse. Psychiatric

Services, 52, 1530-1532.

Thomasson, H. R. (1995). Gender differences in alcohol metabolism: Physiological responses to

ethanol. Recent Developments in Alcoholism, 12, 163-179.

TOPPS-II Interstate Cooperative Study Group. (2003). Drug treatment completion and post-
discharge employment in the TOPPS-II Interstate Cooperative Study. Journal of Substance Abuse
Treatment, 25, 9-18.

26
Tuten, M., & Jones, H. E. (2003). A partner's drug-using status impacts women's drug treatment
outcome. Drug and Alcohol Dependence, 70, 327-330.

Urbano-Marquez, A., Estruch, R., Fernandez-Sola, J., Nicolas, J. M., Pare, J.C., & Rubin, E.
(1995). The greater risk of alcoholic cardiomyopathy and myopathy in women compared with
men. JAMA, 274, 149-154.

van Olphen, J., & Freudenberg, N. (2004). Harlem service providers' perceptions of the impact of
municipal policies on their clients with substance use problems. Journal of Urban Health, 81,
222-231.

Veach, L. J., Remley, T. P. Jr., Kippers, S. M., & Sorg, J. D. (2000). Retention predictors related
to intensive outpatient programs for substance use disorders. American Journal of Drug and
Alcohol Abuse, 26, 417-428.

Wallace, A. E., & Weeks, W. B. (2004). Substance abuse intensive outpatient treatment: Does
program graduation matter? Journal of Substance Abuse Treatment, 27, 27-30.

Walter, H., Gutierrez, K., Ramskogler, K., Hertling, I., Dvorak, A., & Lesch, O. M. (2003).
Gender-specific differences in alcoholism: Implications for treatment. Archives of Women's
Mental Health, 6, 253-258.

Wasilow-Mueller, S., & Erickson, C. K. (2001). Drug abuse and dependency: Understanding
gender differences in etiology and management. Journal of the American Pharmaceutical
Association, 41, 78-90.

Wechsberg, W. M., Craddock, S. G., & Hubbard, R. L. (1998). How are women who enter
substance abuse treatment different than men? A gender comparison from the Drug Abuse
Treatment Outcome Study (DATOS). Drugs & Society, 13, 97-115.

Weiss, S.R., Kung, H.C., & Pearson, J.L. (2003). Emerging issues in gender and ethnic
differences in substance abuse and treatment. Current Women's Health Report, 3, 245-253.

Wickizer, T., Maynard, C., Atherly, A., Frederick, M., Koepsell, T., Krupski, A., & Stark, K.
(1994). Completion rates of clients discharged from drug and alcohol treatment programs in
Washington State. American Journal of Public Health, 84, 215-221.

Williams, M. T., & Roberts, C. S. (1991). Predicting length of stay in long-term treatment for
chemically dependent females. International Journal of the Addictions, 26, 605-613.

Wilsnack, S. C., Vogeltanz, N. D., Klassen, A. D., & Harris, T. R. (1997). Childhood sexual
abuse and women's substance abuse: National survey findings. Journal of Studies on Alcohol, 58,
264-271.

27
Wizemann, T. M., & Pardue, M. (Eds.). (2001). Exploring the biological contributions to human
health: Does sex matter? Washington, DC: National Academy Press. [Available at
http://www.nap.edu/catalog/10028.html]

Wong, C. J., Badger, G. J., Sigmon, S. C., & Higgins, S. T. (2002). Examining possible gender
differences among cocaine-dependent outpatients. Experimental and Clinical
Psychopharmacology, 10, 316-323.

Woodhouse, L. D. (1992). Women with jagged edges: Voices from a culture of substance abuse.
Qualitative Health Research, 2, 262-281.

Wuethrich, B. (2001). Neurobiology: Does alcohol damage female brains more? Science, 291,
2077-2079.

Yin, M., Ikejima, K., Wheeler, M. D., Bradford, B. U., Seabra, V., Forman, D. T., Sato, N., &
Thurman, R. G. (2000). Estrogen is involved in early alcohol-induced liver injury in a rat enteral
feeding model. Hepatology, 31, 117-123.

Young, A. M., Boyd, C., & Hubbell, A. (2002). Self-perceived effects of sexual trauma among
women who smoke crack. Journal of Psychosocial Nursing and Mental Health Services, 40, 46-
53.

Zarkin, G. A., Dunlap, L. J., Bray, J. W., & Wechsberg, W. M. (2002). The effect of treatment
completion and length of stay on employment and crime in outpatient drug-free treatment.
Journal of Substance Abuse Treatment, 23, 261-271.

Zimmermann, G., Pin, M. A., Krenz, S., Bouchat, A., Favrat, B., Besson, J., & Zullino, D. F.
(2004). Prevalence of social phobia in a clinical sample of drug dependent patients. Journal of
Affective Disorders, 83, 83-87.

28
 Chapter 2. Substance Abuse Treatment
Programming for Women: A Literature Review

This chapter summarizes the current literature about substance abuse treatment
programming for women. A definition of substance abuse treatment programming for women is
presented, and the history and origins of this type of programming are briefly described. Current
data are presented about the availability of this type of programming, and selected empirical
research is reviewed on the relationship between gender-specific substance abuse treatment
programming and treatment outcomes among women.

Comprehensive Definition

There is no universally accepted definition of substance abuse treatment programming for

women. In general, this term refers to the delivery of services and treatment that reduce females’
barriers to entering substance abuse treatment and/or address their specific substance abuse
treatment needs. Such programming includes the following core components, which may be
combined:

1. ancillary services intended to increase female clients’ access to substance abuse

treatment, such as child care or transportation services;

2. services intended to address the specific needs of females, such as prenatal and
well-baby care, psychosocial education focusing on issues relevant to women or
parenting, human immunodeficiency virus (HIV) prevention and risk reduction that
targets women, and mental health services that address a woman’s history of abuse
and trauma; and

3. programs and services provided for women only, creating a unique treatment
environment that is more focused on women’s issues than are mixed-gender services.

Although treatment programs addressing females’ barriers to treatment or their specific

needs differ, they often incorporate one or more of the above components. Substance abuse
treatment programming for women may also emphasize a comprehensive service approach to
address psychosocial problems, pregnancy education, parenting, employment, housing, and
trauma services. Such programming may reflect unique treatment philosophies that serve to
empower women and to provide a supportive, nonconfrontational approach to treatment.

Historical Context

Although the substance abuse treatment system has increasingly recognized the need for
programming that addresses women’s specific substance abuse–related problems and barriers to
treatment, women’s treatment needs were obscured for many years. Little research can be
identified before the 1980s describing substance abuse treatment programming for women, but
two seminal studies in this area are highlighted here.

29
 First, an early study of a comprehensive program for substance-dependent women
described the Family Center program initiated in Philadelphia in 1969 (Connaughton, Finnegan,
Schut, & Emich, 1975). Family Center provided outpatient medical (primarily methadone)
treatment and psychosocial services addressing education and treatment to substance-dependent
women. Obstetricians and pediatricians provided perinatal medical services, and personnel
trained in mother-child interaction and early childhood development subsequently joined the
staff. Other services included a clothing bank and a small food bank for registrants, and staff
organized women-only and parent education groups.

Second, in 1975, using pregnancy as the focus, the National Institute on Drug Abuse
(NIDA) initiated funding for a series of comprehensive drug treatment demonstration grants for
women in Detroit; Houston; New York; Philadelphia; Washington, DC; and San Rafael,
California (Beschner & Brotman, 1977). The New York City program—the Pregnant Addicts
and Addicted Mothers Program (PAAM)—was inaugurated in 1975, emphasizing
comprehensive care and providing onsite addiction treatment, medical services, individual and
group counseling, child development services, parent education classes, child care, and
developmental assessments of infants (Suffet & Brotman, 1984). All services were housed on the
same floor of one building, which facilitated communication between providers and patient
access to services. PAAM concentrated on helping women addicted to opiates or methadone
have a normal pregnancy and deliver a healthy newborn, as well as helping the newborn develop
normal cognitive and motor abilities. The comprehensive approach to treatment embedded in the
PAAM treatment model demonstrated positive outcomes, such as treatment compliance and
favorable newborn outcomes (Suffet & Brotman, 1984). PAAM was initiated at the Center for
Comprehensive Health Practice of New York Medical College in 1969 as a pilot project offering
obstetrical, pediatric, and psychological services to East Harlem mothers and their children. The
program eventually received two successive 3-year NIDA grants (1975–1981) and began
operating under contract to the New York State Division of Substance Abuse Services.

The crack cocaine epidemic of the 1980s focused attention on female crack abusers and,
in particular, on pregnant women and their children. The media focused on drug-exposed infants,
resulting in heightened concern for the devastating and costly effects of prenatal cocaine
exposure on newborns (Hartman & Golub, 1999; Lyons & Rittner, 1998). This attention resulted
in increased funding for treatment programs serving females. Block grant legislation was
amended by the Federal Government in 1984 to require that each State set aside 5 percent of its
block grant allocation to provide new or expanded substance abuse treatment services for
women. By 1988, this set-aside for women’s services had increased to 10 percent, and in 1990
the General Accounting Office (GAO) called for an urgent national response to the growing issue
of drug-exposed infants in the United States (Grella & Greenwell, 2004). Within the U.S. Public
Health Service (PHS), branches of the Alcohol, Drug Abuse, and Mental Health Administration
(ADAMHA), the National Institute on Child Health and Human Development (NICHD), and the
Health Resources and Services Administration (HRSA) all implemented special programs for
females with substance use disorders.

During the 1980s and 1990s, an increasing number of Federal programs were geared
specifically to substance-abusing mothers. The NIDA “Perinatal-20” funded 20 demonstration
grant projects in 1989 and 1990 that focused on the treatment of drug-abusing pregnant women

30
and their offspring. The intent of the Perinatal-20 was to conduct treatment research and create
new treatment slots for women and their children (Kandall, 1996). Each of the 20 projects was
designed to evaluate either a comprehensive treatment program composed of an integrated
system of services or a specific targeted therapeutic intervention embedded in a comprehensive
continuum of care. Each study targeted in its evaluation drug-abusing women in treatment either
with or without their children (Rahdert, 1996). Through these funding and policy initiatives,
availability of treatment services for women increased, and this increase enabled researchers and
evaluators to study gender-specific treatment processes and outcomes.

The Substance Abuse and Mental Health Services Administration (SAMHSA) and its
predecessor, the Alcohol, Drug Abuse, and Mental Health Administration, initiated important
programs for women with substance use disorders. One program managed under both agencies,
the Pregnant and Postpartum Women and their Infants (PPWI) Demonstration Grant Program,
awarded 147 grants in 37 States between 1989 and 1993. These projects provided comprehensive
prevention, intervention, and treatment services to substance-abusing pregnant and postpartum
women (Carter & Larson, 1997). These programs also provided health care services to the infants
of women in treatment. An evaluation of 90 of the 147 demonstration grant projects found them
to be highly successful in improving the coordination, availability, and accessibility of health
care and alcohol and drug treatment for pregnant and postpartum women, with at least one third
of the women treated by these programs reporting a reduction in drug use (Carter & Larson,
1997).

In addition to the PPWI Demonstration Grant Program, SAMHSA’s Residential Women

and Children (RWC) and the Pregnant and Postpartum Women (PPW) Demonstration Program
awarded 5-year grants to 70 projects between 1993 and 1995 (Clark, 2001). Both of these
initiatives were designed to support comprehensive residential treatment services, including
primary health care, mental health assessments and counseling, and other social services for
substance-abusing women and their children. The Center for Substance Abuse Treatment
(CSAT) conducted a cross-site evaluation of 50 of these programs. One of the key findings from
that evaluation was that between 1993 and 1996, the number of women who reported the use of
illicit drugs decreased by between 73 and 80 percent from intake to postdischarge (Carter &
Larson, 1997). Other benefits of these programs included reduction of adverse pregnancy
outcomes, reduction of criminal involvement, and improvement in retaining custody of children
(Substance Abuse and Mental Health Services Administration [SAMHSA], 2001). In addition,
47 of the 50 RWC/PPW projects obtained funding for the continuation of services beyond the
original CSAT funding.

Today, SAMHSA, through CSAT and the Center for Mental Health Services (CMHS),
continues to fund programs providing comprehensive residential substance abuse treatment
services for pregnant, postpartum, and/or parenting women and their minor children. A variety of
funding vehicles supports these programs, including Targeted Capacity Expansion, Addiction
Treatment for the Homeless, HIV Outreach, and Drug Court grants. An example of one of these
programs is the Women, Co-Occurring Disorders and Violence Study, a 5-year initiative jointly
supported by the three centers of SAMHSA to study women with substance abuse and mental
health disorders who have histories of violence. Knowledge gained from this study is expected to
be useful in advancing national, State, and local policy that affects how the various service

31
systems respond to women with co-occurring disorders and histories of violence. As of June
2004, CSAT had funded over 100 grantees targeting women. In addition to SAMHSA’s efforts,
some states have created or funded treatment programs or provided priority access to treatment
for pregnant substance abusers (Dailard & Nash, 2000).

Availability of Substance Abuse Treatment Programming for Women

Limited information is available about the prevalence of components of substance abuse

treatment programming for women. Services are not clearly defined, and the services offered
may be available to only a limited number of clients because of restricted resources.
Nevertheless, the data provide important insight about the types and scope of treatment options
for females.

Table 2.1 presents data about the prevalence of child care or prenatal care services offered
by substance abuse treatment facilities. Nationally across studies, as shown in the table, 8 percent
of substance abuse treatment facilities offer child care services, and 7 percent offer prenatal care
services, although the rate in urban settings may be higher.

Table 2.1 Percentages of Substance Abuse Treatment Facilities Offering Child Care or
Prenatal Care Services
Facilities Offering Facilities Offering
Data Source Child Care Services Prenatal Care Services
2003 N-SSATS (SAMHSA, 2004) 7.9 Not available
1998 UFDS (OAS, 2000) 8.6 6.5
Opioid Treatment Program Study 7.5 Not available
(CSAT, 2003)
1994 Los Angeles Study (Grella, Not available 30.4
Polinsky, Hser, & Perry, 1999)

The 2003 National Survey of Substance Abuse Treatment Services (N-SSATS) found that
14 percent of substance abuse treatment facilities offered special programs for pregnant or
postpartum women. Although this figure cannot be compared to percentages from previous years
due to a change in the N-SSATS survey instrument, the percentage of facilities offering special
programs for pregnant or postpartum women remained relatively stable between 1997 and 2002.
The 2003 N-SSATS also found that 35 percent of substance abuse treatment facilities offered
special programs for women, a figure that has remained relatively stable ever since an increase
from 1998 to 1999 (SAMHSA, 2004). Among the major types of care, special programs for
women most often were offered at combined residential and outpatient facilities (Figure 2.1).
More than one third of all facilities offered transportation assistance to treatment.

In a survey of 172 opioid treatment programs in 15 states, CSAT (2003) found that 49
percent offered special services for women, and 59 percent offered special services for pregnant
women. Among a subset of 108 of these programs in 14 states, Wechsberg and colleagues (2001)

32
found that 83 percent provided priority admission for pregnant women, 58 percent offered
counseling to families, and 9 percent reported matching female clients with female counselors.

Figure 2.1 Percentages of Facilities Offering Special Programs for Women or Pregnant
Women, by Type of Care: N-SSATS, 2003

Source: SAMHSA, Office of Applied Studies, National Survey of Substance Abuse Treatment Services (N-SSATS,
2003)

Using Los Angeles County data, a 1994 study of 161 drug treatment programs for adults
found that 42 percent provided activities for children, 39 percent targeted pregnant women, and
19 percent served women only (Grella et al., 1999). Compared with mixed-gender programs,
women-only programs were more likely to provide priority admission for pregnant women,
charge no fees, and plan for longer treatment duration. Women-only programs also were more
likely than mixed-gender programs to offer pediatric/well-baby care, children’s activities, and
housing assistance. In addition, women-only programs were more likely to serve Latinos and
Native Americans and to accept Medicaid payment than were mixed-gender programs. The
authors stated that the high percentage of women-only programs receiving public funding
generally reflected the lower economic status of females.

Effectiveness of Substance Abuse Treatment Programming for Women

Although studies evaluating substance abuse treatment programming for women in the
past often lacked control groups or analyzed small samples that limited their conclusions about
effectiveness (McCrady & Raytek, 1993), recent research has shown promising results. Studies
have demonstrated higher rates of retention when women in residential treatment are allowed to
live with their children (Szuster, Rich, Chung, & Bisconer, 1996). Additionally, several studies
have demonstrated better outcomes for women in outpatient treatment with comprehensive

33
support services, including pregnancy-related services, parenting/training classes, child care, and
family services (Grella & Greenwell, 2004).

This section provides a review of the literature evaluating the effectiveness of substance
abuse treatment programming for women. Studies published between 1980 and 2000 of
substance abuse treatment programming for women were identified through a systematic
literature search. To be included in this review, studies must have explicitly defined the
population at risk, described the intervention, and presented outcome measures to evaluate the
impact of substance abuse treatment programming. The outcome measures included retention in
treatment and changes in substance use, mental health symptoms, perinatal/birth outcomes,
employment, self-reported health status, and HIV risk. A total of 37 studies were identified; 7
were randomized controlled trials, and 30 were nonrandomized studies. Detailed methods for this
review have been published elsewhere (Ashley, Marsden, & Brady, 2003).

Optimally, health interventions are evaluated through a rigorous randomized controlled

trial (or series of trials), the standard for establishing efficacy (Sackett, Haynes, Guyatt, &
Tugwell, 1991).1 The 7 randomized trials differed in interventions and methodologies, while the
30 nonrandomized studies employed a variety of descriptive, cohort, preexperimental, and
quasi-experimental study designs. Of the seven randomized, controlled trials reviewed here,
Dahlgren and Willander’s (1989) study came closest to the optimal study design: females were
randomly assigned to treatment in either a regular ward/alcoholism treatment center or a
women-only outpatient or residential setting, and results were compared after 2 years.

Across the 37 populations analyzed, 36 studies reported improved treatment outcomes for
female clients. All 7 randomized controlled trials showed positive results (Table 2.2), and 29 of
the 30 nonrandomized studies showed positive results. The one study that did not report
improved treatment outcomes was conducted in Australia. This study found no differences in
treatment outcomes among females in a women-only program and in two mixed-gender
treatment programs (Copeland, Hall, Didcott, & Biggs, 1993). However, more lesbian women,
women with dependent children, and women with a history of childhood sexual abuse or
maternal substance abuse participated in the women-only program than in the mixed-gender
programs.

This review focuses primarily on three components of gender-specific treatment: child

care services, prenatal care services, and women-only treatment. In addition, the effects of two
additional components of substance abuse treatment programming for women were examined:
mental health programming and supplemental education sessions that address women-focused
topics. Transportation was provided infrequently within the studies reviewed and was not
evaluated by any study as a primary intervention; therefore, it is not discussed independently
from other components.

1
However, studies that start out as randomized controlled trials may not be able to sustain the original study
design because subjects may drop out to enter a treatment program of choice that offers special child care services,
has a more convenient location, or offers outpatient (vs. inpatient) treatment, for example.

34
Table 2.2 Randomized Studies of the Effectiveness of Substance Abuse Treatment
Programming for Women
Control
Study Citation N Population Interventions Condition Outcomes
Carroll, Chang, 14 Pregnant, Prenatal care, Standard At delivery:
Behr, Clinton, outpatient therapeutic child methadone
& Kosten methadone care during treatment Increased
(1995) clinic treatment visits, gestational length,
patients monetary rewards birthweight, and
for abstinence, number of
relapse prevention prenatal care
visits; no change
in maternal drug
use
Dahlgren & 200 Women Women-only Treatment in At 2-year follow-
Willander entering outpatient and regular wards up:
(1989) alcohol residential treatment and alcoholism
treatment treatment center Decreased alcohol
use, decreased job
loss
Elk, Mangus, 12 Pregnant Contingent Behaviorally At delivery:
Rhodes, cocaine- reinforcement for based drug
Andres, & dependent cocaine abstinence counseling, Improved
Grabowski women who and attending weekly prenatal perinatal
(1998) had used the prenatal visits, visits outcomes and
drug during transportation, child increased prenatal
this care, behaviorally care but no
pregnancy based drug significant
but had counseling, weekly difference in
ceased use prenatal visits abstinence from
cocaine
Hiller, Rowan- 17 Women in Weekly sessions on No specialized On intervention
Szal, residential women’s health, treatment completion:
Bartholomew, treatment HIV/AIDS intervention
& Simpson prevention, and Increased self-
(1996) assertiveness/ esteem, more
communication positive attitudes
skills toward practicing
safer sex
Hughes et al. 53 Female Children allowed to Standard (no By discharge:
(1995) cocaine live with mothers in child)
abusers with a therapeutic community Improved
children community treatment retention
(continued)

35
Table 2.2 Randomized Studies of the Effectiveness of Substance Abuse Treatment
Programming for Women (continued)

Control
Study Citation N Population Interventions Condition Outcomes
O’Neill et al. 73 Pregnant Six-session Methadone At 9-month
(1996) women cognitive-behavioral maintenance follow-up:
enrolled in intervention focused treatment,
methadone on the acquisition of counseling, and Reduction of
maintenance skills aimed at advice about injecting risk
programs for helping prevent HIV risk-taking behaviors
pregnant relapse to needle behaviors associated with
women sharing and to “typical” drug use
unsafe sex, and binge use, no
methadone change in sexual
maintenance risk behaviors, no
treatment, change in drug
counseling and use per se
advice about HIV
risk-taking
behaviors
Volpicelli, 84 Cocaine- Parenting skills Case At 12-month
Markman, dependent class, access to a management– follow-up:
Monterosso, mothers psychiatrist, oriented
Filing, & individual therapy outpatient Decreased drug
O’Brien (2000) sessions, GED treatment use, increased
classes program program retention,
no change in
psychosocial
functioning
(including
employment
status)

Although in clinical trials, all subjects assigned to a particular condition (e.g., child care
services) will normally receive the service, in studies of substance abuse treatment programs,
clients in programs offering services may not actually receive them. Thus, there is the potential in
such studies for Type II error—that is, differences in outcomes between programs with women’s
services and those without such services may be identified as small or nonexistent because not all
of the female clients at programs offering services received them. Findings are discussed below.

Child Care Services

It is difficult to analyze the unique impact of child care services on treatment outcomes
for females because in some studies, the service was bundled with other intervention services. In
other studies, child care was provided to study participants, but its impact was not evaluated
(Carroll, et al., 1995; Elk et al., 1997). Most studies that evaluated the effectiveness of providing

36
child care services to female clients in substance abuse treatment examined services for children
living with their mothers in a residential treatment program. In one clinical trial, females who
lived with their children in therapeutic community treatment programs remained in treatment
significantly longer (mean length of stay [LOS] = 300 days) than females whose children were
placed with caretakers (mean LOS = 102 days) (Hughes et al., 1995). Less rigorous studies also
found that program changes enabling women to bring their children into residential treatment
were associated with increased LOS (e.g., Stevens, Arbiter, & Glider, 1989; Wobie, Eyler,
Conlon, Clarke, & Behnke, 1997). One study found that measures of depression were lower and
measures of self-esteem were higher for females whose infants accompanied them to the
treatment facility compared with females who did not have their infants in the treatment facility
(Wobie et al., 1997). This study suggested that the earlier a mother’s infant resides with her in
the treatment setting, the longer the mother will stay in treatment.

Prenatal Care Services

One small-scale randomized trial compared standard methadone maintenance to an

enhanced treatment program that offered prenatal care services, relapse-prevention groups,
positive contingency awards for abstinence, and therapeutic child care services (Carroll et al.,
1995). A second nonrandomized study evaluated a similar intervention (Chang, Carroll, Behr, &
Kosten, 1992). Both studies found that females in the enhanced methadone program made 3
times as many prenatal visits and experienced better birth outcomes than females in the standard
program; however, both studies analyzed small sample sizes. Another randomized study
combined contingency reinforcement for abstinence with weekly prenatal visits, transportation,
child care, and behaviorally based drug counseling and found improved perinatal outcomes and
increased prenatal care but no change in substance use at delivery (Elk et al., 1998).

Other studies examined the effectiveness of mental health interventions coupled with
prenatal care, child care, human immunodeficiency virus (HIV) counseling, parenting and
nutrition classes, and transportation (Elk et al., 1997; Kukko & Halmesmaki, 1999). These
studies reported high rates of abstention from drug use or reduced drug use, retention in
treatment, compliance with prenatal care, and good perinatal outcomes.

Women-Only Treatment

Although the literature contains many reports of women-only treatment programs, only
one randomized study in Sweden compared females in a women-only treatment unit consisting of
an outpatient clinic and a residential ward with females placed in the care of traditional
mixed-gender alcoholism treatment centers (Dahlgren & Willander, 1989). A 2-year follow-up
showed a more successful rehabilitation in terms of alcohol consumption and social adjustment
(including employment status) for the females treated in the specialized women-only unit.

Using a nonrandomized design, Grella and colleagues (1999) found that females treated
in publicly funded women-only residential treatment programs in Los Angeles reported they had
more problems, such as mental health issues and substance severity, than females at mixed-
gender programs. However, the clients in women-only programs actually spent more time in
treatment and were more than twice as likely to complete treatment than females in mixed-gender

37
programs. In contrast, programs that treat male and female clients together are less able to attract
and retain especially vulnerable females, such as lesbian women, women with a history of
physical or sexual violence, women who have worked as prostitutes, and single parents
(Copeland & Hall, 1992; Fullilove, Lown, & Fullilove, 1992; Grella, 1997; Pottieger, Inciardi, &
Tressell, 1996).

Copeland and colleagues (1993) compared the results achieved by subjects in a

women-only treatment program with those for subjects in two traditional mixed-gender treatment
programs in Australia. Their study found no statistically significant differences at 6 months
following treatment on any treatment outcome measure between the females in the two types of
programs, including self-reports of alcohol or drug use, a detoxification episode, a drug-related
conviction, and Alcoholics Anonymous/Narcotics Anonymous (AA/NA) attendance. However,
at entry into treatment, the women-only program served more lesbian women, women with
dependent children, women sexually abused in childhood, and women with a maternal history of
substance dependence than did the mixed-gender programs.

Mental Health Services

A number of studies evaluated the effectiveness of mental health programming for

females in substance abuse treatment. Volpicelli and colleagues (2000) randomly assigned
cocaine-dependent mothers to either a case management outpatient treatment program or to a
psychosocially enhanced treatment (PET) program that offered access to a psychiatrist, individual
therapy sessions, parenting classes, and high school equivalency education. Overall, PET patients
averaged 15.4 weeks in treatment compared with 13.9 weeks for the case management group.
Although cocaine use decreased from baseline levels in both groups, the PET group had used
cocaine on significantly fewer days at 12-month follow-up than the case management group. The
investigators suggested that individual therapy may have been the primary cause of the PET
group’s marginally better outcomes because individual therapy was the most extensively utilized
service in the PET group.

Another study randomly assigned pregnant injecting drug users either to (1) a six-session
cognitive-behavioral intervention addressing relapse prevention, needle sharing, and unsafe sex
in addition to their usual methadone maintenance treatment or (2) their usual methadone
maintenance treatment only. Results indicated that the intervention group had significantly
reduced some HIV risk-taking behaviors at a 9-month follow-up (O’Neill et al., 1996).

Nonrandomized studies have evaluated the effectiveness of outpatient individual

counseling and/or group therapy in combination with vocational and recreational activities,
medical care, parenting classes, relaxation therapy, child care, and prenatal care services (Bander,
Stilwell, Fein, & Bishop, 1983; Field et al., 1998; Kukko & Halmesmaki, 1999). Results
included abstinence or lower incidence of substance use, an increase in education and
employment, improved mother-child interactions, lowered incidence of preterm birth, increased
gestational age and birthweight, improved child physical and psychosocial functioning, and
lowered repeat pregnancy. In another study, researchers examined the effectiveness of a therapy
group addressing grief and loss among females enrolled in a gender-specific residential substance
abuse treatment program (McComish et al., 1999). Females who participated in the grief group

38
remained in treatment longer and had higher self-esteem at follow-up than those enrolled in the
same residential substance abuse treatment program but who did not participate in the grief
group.

Use of Supplemental Education Sessions

Research has shown the effectiveness of supplemental education sessions for females in
substance abuse treatment. One randomized study evaluated a treatment program that
supplemented standard substance abuse treatment with weekly psychosocial workshops on topics
covering breast health and breast self-examination; sexual and reproductive anatomy; sexually
transmitted diseases (STDs), including HIV and acquired immune deficiency syndrome (AIDS)
prevention; plus assertiveness and communication skills (Hiller et al., 1996). This approach
improved attitudes toward practicing safer sex and increased self-esteem. Several nonrandomized
studies also assessed supplemental psychoeducational sessions and workshops. These studies
evaluated standard substance abuse treatment supplemented with workshops as the primary focus
of an intervention (Bartholomew, Rowan-Szal, Chatham, & Simpson, 1994) and in combination
with other intervention components, including child care and prenatal or health care (Field et al.,
1998; Knight, Hood, Logan, & Chatham, 1999; Saunders, 1993; Wobie et al., 1997), the
provision of educational materials and behavioral strategies (Walitzer & Connors, 1997), and
comprehensive program restructuring to address the special needs of women (Stevens & Arbiter,
1995; Stevens et al., 1989; Zankowski, 1987).

Summary

This review of the current knowledge about substance abuse treatment programming for
women suggests that for substance-abusing females, treatment programming that includes
auxiliary and/or wraparound services, such as child care services, prenatal care services,
women-only treatment, mental health services, and supplemental services and workshops
addressing women-focused topics, can be beneficial. Positive treatment outcomes included
decreased substance use, increased treatment retention, improved perinatal/birth outcomes and
prenatal care, improvements in self-esteem and depression, and HIV risk reduction. Programs
that narrowly define the problems that females face solely as alcohol or other drug abuse may not
improve outcomes substantially.

39
References

Ashley, O. S., Marsden, M. E., & Brady, T. M. (2003). Effectiveness of substance abuse
treatment programming for women: A review. American Journal of Drug and Alcohol Abuse, 29,
19-53.

Bander, K. W., Stilwell, N. A., Fein, E., & Bishop, G. (1983). Relationship of patient
characteristics to program attendance by women alcoholics. Journal of Studies on Alcohol, 44,
318-327.

Bartholomew, N. G., Rowan-Szal, G. A., Chatham, L. R., & Simpson, D. D. (1994).

Effectiveness of a specialized intervention for women in a methadone program. Journal of
Psychoactive Drugs, 26, 249-255.

Beschner, G., & Brotman, R. (Eds.). (1977). Symposium on comprehensive health care for
addicted families and their children: May 20 & 21, 1976, New York, New York (DHEW
Publication No. ADM 77-480, NIDA Services Research Report). Rockville, MD: National
Institute on Drug Abuse.

Carroll, K. M., Chang, G., Behr, H., Clinton, B., & Kosten, T. R. (1995). Improving treatment
outcome in pregnant, methadone-maintained women: Results from a randomized clinical trial.
American Journal on Addictions, 4, 56-59.

Carter, L. S., & Larson, C. S. (1997). Drug-exposed infants. Future of Children, 7, 157-160.

Center for Substance Abuse Treatment. (2003). Evaluation of the opioid treatment program
accreditation study: Final report [unpublished]. Rockville, MD: Substance Abuse and Mental
Health Services Administration.

Chang, G., Carroll, K. M., Behr, H. M., & Kosten, T. R. (1992). Improving treatment outcome in
pregnant opiate-dependent women. Journal of Substance Abuse Treatment, 9, 327-330.

Clark, H. W. (2001). Residential substance abuse treatment for pregnant and postpartum women
and their children: Treatment and policy implications. Child Welfare, 80, 179-198.

Connaughton, J. F. Jr, Finnegan, L. P., Schut, J., & Emich, J. P. (1975). Current concepts in the
management of the pregnant opiate addict. Addictive Diseases, 2(1-2), 21-35.

Copeland, J., & Hall, W. (1992). A comparison of women seeking drug and alcohol treatment in
a specialist women’s and two traditional mixed-sex treatment services. British Journal of
Addiction, 87, 1293-1302.

Copeland, J., Hall, W., Didcott, P., & Biggs, V. (1993). A comparison of a specialist women’s
alcohol and other drug treatment service with two traditional mixed-sex services: Client
characteristics and treatment outcome. Drug and Alcohol Dependence, 32, 81-92.

40
Dahlgren, L., & Willander, A. (1989). Are special treatment facilities for female alcoholics
needed? A controlled 2-year follow-up study from a specialized female unit (EWA) versus a
mixed male/female treatment facility. Alcoholism, Clinical and Experimental Research, 13,
499-504.

Dailard, C., & Nash, E. (2000). States response to substance abuse treatment among pregnant
women. The Guttmacher Report on Public Policy, 3(6), 3-6.

Elk, R., Mangus, L. G., LaSoya, R. J., Rhoades, H. M., Andres, R. L., & Grabowski, J. (1997).
Behavioral interventions: Effective and adaptable for the treatment of pregnant
cocaine-dependent women. Journal of Drug Issues, 27, 625-658.

Elk, R., Mangus, L., Rhoades, H., Andres, R., & Grabowski, J. (1998). Cessation of cocaine use
during pregnancy: Effects of contingency management interventions on maintaining abstinence
and complying with prenatal care. Addictive Behaviors, 23(1), 57-64.

Field, T. M., Scafidi, F., Pickens, J., Prodromidis, M., Pelaez-Nogueras, M., Torquati, J., Wilcox,
H., Malphurs, J., Schanberg, S., & Kuhn, C. (1998). Polydrug-using adolescent mothers and their
infants receiving early intervention. Adolescence, 33(129), 117-143.

Fullilove, M. T., Lown, E. A., & Fullilove, R. E. (1992). Crack ‘hos and skeezers: Traumatic
experiences of women crack users. Journal of Sex Research, 29, 275-287.

Grella, C. E. (1997). Services for perinatal women with substance abuse and mental health
disorders: The unmet need. Journal of Psychoactive Drugs, 29, 67-78.

Grella, C. E., & Greenwell, L. (2004). Substance abuse treatment for women: Changes in the
settings where women received treatment and types of services provided, 1987-1998. Journal of
Behavioral Health Services & Research, 21, 367-382.

Grella, C. E., Polinsky, M. L., Hser, Y. I., & Perry, S. M. (1999). Characteristics of women-only
and mixed-gender drug abuse treatment programs. Journal of Substance Abuse Treatment, 17,
37-44.

Hartman, D. M., & Golub, A. (1999). The social construction of the crack epidemic in the print
media. Journal of Psychoactive Drugs, 4, 423-433.

Hiller, M. L., Rowan-Szal, G. A., Bartholomew, N. G., & Simpson, D. D. (1996). Effectiveness
of a specialized women’s intervention in a residential treatment program. Substance Use &
Misuse, 31, 771-783.

Hughes, P. H., Coletti, S. D., Neri, R. L., Urmann, C. F., Stahl, S., Sicilian, D. M., & Anthony, J.
C. (1995). Retaining cocaine-abusing women in a therapeutic community: The effect of a child
live-in program. American Journal of Public Health, 85, 1149-1152.

41
Kandall, S. R. (1996). Substance and shadow: Women and addiction in the United States.
Cambridge, MA: Harvard University Press.

Knight, D. K., Hood, P. E., Logan, S. M., & Chatham, L. R. (1999). Residential treatment for
women with dependent children: One agency’s approach. Journal of Psychoactive Drugs, 31,
339-351.

Kukko, H., & Halmesmaki, E. (1999). Prenatal care and counseling of female drug-abusers:
Effects on drug abuse and perinatal outcome. Acta Obstetricia Et Gynecologica Scandinavica,
78(1), 22-26.

Lyons, P., & Rittner, B. (1998). The construction of the crack babies phenomenon as a social
problem. American Journal of Orthopsychiatry, 2, 313-320.

McComish, J. F., Greenberg, R., Kent-Bryant, J., Chruscial, H. L., Ager, J., Hines, F., &
Ransom, S. B. (1999). Evaluation of a grief group for women in residential substance abuse
treatment. Substance Abuse, 20(1), 45-58.

McCrady, B. S., & Raytek, H. (1993). Women and substance abuse: Treatment modalities and
outcomes. In E. S. L. Gomberg & T. D. Nirenberg (Eds.), Women and substance abuse (pp.
314-338). Norwood, NJ: Ablex.

Office of Applied Studies. (2000). Uniform Facility Data Set (UFDS):1998 data on substance
abuse treatment facilities (DHHS Publication No. SMA 00-3463, Drug and Alcohol Services
Information System Series S-10). Rockville, MD: Substance Abuse and Mental Health Services
Administration. [Available at http://www.oas.samhsa.gov/dasis.htm#nssats2]

O’Neill, K., Baker, A., Cooke, M., Collins, E., Heather, N., & Wodak, A. (1996). Evaluation of a
cognitive-behavioural intervention for pregnant injecting drug users at risk of HIV infection.
Addiction, 91, 1115-1125.

Pottieger, A. E., Inciardi, J. A., & Tressell, P. A. (1996, August). Barriers to treatment entry for
women crack users. Paper presented at the 91st Annual Meeting of the American Sociological
Association, New York.

Rahdert, E. R. (1996). Introduction to the Perinatal-20 Treatment Research Demonstration

Program. In E. R. Rahdert (Ed.), Treatment for drug exposed women and their children (pp. 1-5,
NIH Publication No. 96-3632, NIDA Research Monograph 166). Rockville, MD: National
Institute on Drug Abuse. [Available as a PDF at
http://www.drugabuse.gov/pdf/monographs/monograph166/download.html]

Sackett, D. L., Haynes, R. B., Guyatt, G. H., & Tugwell, P. (1991). Clinical epidemiology: A
basic science for clinical medicine (2nd ed.). Boston, MA: Little, Brown and Co.

Saunders, E. J. (1993). A new model of residential care for substance-abusing women and their
children. Adult Residential Care Journal, 7, 104-117.

42
Stevens, S. J., & Arbiter, N. (1995). A therapeutic community for substance-abusing pregnant
women and women with children: Process and outcome. Journal of Psychoactive Drugs, 27,
49-56.

Stevens, S., Arbiter, N., & Glider, P. (1989). Women residents: Expanding their role to increase
treatment effectiveness in substance abuse programs. International Journal of the Addictions, 24,
425-434.

Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (2001).
Benefits of residential substance abuse treatment for pregnant and parenting women: Highlights
from a study of 50 demonstration programs of the Center for Substance Abuse Treatment.
Rockville, MD: Substance Abuse and Mental Health Services Administration. [Available at
http://csat.samhsa.gov/residential/residential_background.htm]

Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (2004).
National Survey of Substance Abuse Treatment Services (N-SSATS): 2003. Data on substance
abuse treatment facilities. DASIS Series: S-24, DHHS Publication No. (SMA) 04-3966.
Rockville, MD.

Suffet, F., & Brotman, R. (1984). A comprehensive care program for pregnant addicts:
Obstetrical, neonatal, and child development outcomes. International Journal of the Addictions,
19, 199-219.

Szuster, R. R., Rich, L. L., Chung, A., & Bisconer, S. W. (1996). Treatment retention in
women’s residential chemical dependency treatment: The effect of admission with children.
Substance Use & Misuse, 31, 1001-1013.

Volpicelli, J. R., Markman, I., Monterosso, J., Filing, J., & O’Brien, C. P. (2000). Psychosocially
enhanced treatment for cocaine-dependent mothers: Evidence of efficacy. Journal of Substance
Abuse Treatment, 18, 41-49.

Walitzer, K. S., & Connors, G. J. (1997). Gender and treatment of alcohol-related problems. In
R. W. Wilsnack & S. C. Wilsnack (Eds.), Gender and alcohol: Individual and social
perspectives (pp. 445-461). New Brunswick, NJ: Rutgers Center of Alcohol Studies.

Wechsberg, W. M., Suerken, C., Crum, L., Berkman, N., Kasten, J., Fulmer, E., Magura, S., &
Stanton, A. (2001, October 22). Availability of special services for women in methadone
treatment: Results from a national study. Paper presented at the 129th Annual Meeting and
Exposition of the American Public Health Association, Atlanta, GA.

Wobie, K., Eyler, F. D., Conlon, M., Clarke, L., & Behnke, M. (1997). Women and children in
residential treatment: Outcomes for mothers and their infants. Journal of Drug Issues, 27,
585-606.

Zankowski, G. L. (1987). Responsive programming: Meeting the needs of chemically dependent

women. Alcoholism Treatment Quarterly, 4(4), 53-66.

43
44
 Chapter 3. Data and Methods Used in This Report

Analyses in this report are based on data from a nationally representative sample of
substance abuse treatment facilities and clients in the Alcohol and Drug Services Study (ADSS).
This chapter provides information about ADSS and an overview of the analytic methods used in
this report.

Data Source

ADSS provides detailed information on the characteristics of substance abuse treatment

facilities and their clients. Conducted in three phases between 1996 and 1999, ADSS collected
data by administering questionnaires to substance abuse treatment facility directors through
telephone interviews, abstracting client record data, and conducting postdischarge personal
interviews with clients. ADSS was sponsored by the Substance Abuse and Mental Health
Services Administration (SAMHSA), part of the U.S. Department of Health and Human Services
(DHHS). Data collection was carried out by Brandeis University and Westat, Inc., under a
contract with SAMHSA’s Office of Applied Studies (OAS). In-depth information about ADSS
methods is described in another SAMHSA report (OAS, 2003a) and on the OAS website at
http://www.oas.samhsa.gov/adss.htm. Data collection instruments for ADSS’s three phases can
be found at http://www.oas.samhsa.gov/adss.htm#Qn. Data used in this report were drawn from
the first two phases of the study.

ADSS Phase I

The Phase I target population comprised active public and private substance abuse
treatment facilities. Facilities excluded from the survey included halfway houses without paid
counselors, solo practitioners, correctional facilities, military/Department of Defense (DoD)
facilities, Indian Health Service (IHS) facilities, and facilities that perform intake and referral
only. Phase I of the survey was conducted from December 1996 to June 1997 among a nationally
representative sample of substance abuse treatment facilities.

The ADSS Phase I questionnaire was administered in about 50 minutes and used
telephone-administered structured interview methods with substance abuse treatment facility
directors. The questionnaire was mailed 2 weeks in advance and required approximately 3 hours
for respondents to obtain answers to questions prior to the telephone data collection.
Respondents were assured that information collected during both Phases I and II would be
handled in the strictest confidence. Furthermore, information collected was protected from civil
and criminal subpoena by a Certificate of Confidentiality issued by the DHHS.

ADSS employed a national sampling design including all 50 states and the District of
Columbia. Substance abuse treatment facilities were assigned to one of seven strata based on the
type of care delivered to clients: (1) hospital inpatient, (2) other residential, (3) outpatient—
predominantly methadone, (4) outpatient—almost exclusively alcohol, (5) outpatient—all other,
(6) combined, or (7) unknown. The design oversampled hospital inpatient, residential, outpatient

45
methadone, and combined facilities. The Phase I questionnaire collected information on each
facility’s organizational characteristics; facility counts of active clients in treatment2 and special
programs offered to specific types of clients, using a reference date of October 1, 1996; and
12-month facility data on specific services offered (OAS, 2002).

ADSS Phase II

The ADSS Phase II target population comprised clients discharged from nonhospital
residential or outpatient substance abuse treatment facilities. Discharged clients were those who
ended treatment in some way during the 6-month period preceding the data collection visit,
regardless of when they were admitted.3 Clients excluded from this phase were those discharged
from hospital inpatient facilities, facilities in which all clients were treated for alcohol abuse
only, and facilities outside a nationally representative subset of 62 primary sampling units
(PSUs). Phase II was conducted from August 1997 to April 1999. A client record abstraction
form was used to collect information from the client treatment records during site visits to the
facilities.

The Phase II client sample was drawn from client discharges from the 280 Phase II
respondent facilities. Substance abuse treatment discharges during the most recent 6 months were
listed for those Phase II facilities that participated in all steps of the Phase II study protocol, and a
sample of client discharge records was randomly selected from the client lists. To be included on
the list, clients must have been an active treatment client, had at least 1 day in treatment or at
least one outpatient visit, and ended treatment during the 6-month period. The Phase II record
abstraction form collected demographic and background, medical, substance abuse history,
mental disorder, and discharge information.

ADSS Phase III

ADSS Phase III included personal follow-up interviews with selected subgroups of Phase
II discharged clients and the collection of postdischarge urine samples. Phase III data were not
included in this analysis.

Analysis Samples

Facility directors from a total of 2,395 substance abuse treatment facilities completed the
Phase I survey (Table 3.1), and 280 of those facilities participated in the Phase II data collection.

2
Active clients were defined as individuals who (1) had been admitted to the treatment facility and for
whom a substance abuse treatment plan had been developed, (2) had been seen on a scheduled appointment basis for
substance abuse treatment at least once during the preceding month or were inpatients/residential patients on October
1, 1996, and (3) had not been discharged from treatment as of October 1, 1996.
3
These clients included those who were formally discharged on completion of treatment; dropped out of
treatment or otherwise failed to return; were terminated by the facility (for noncompliance with rules, lack of
payment, termination of type of care, etc.); were incarcerated and ended treatment; died; were transferred to another
facility, thereby ending their treatment at the sampled facility; or in any other way ended treatment at the sampled
facility during the 6-month reference period.

46
 Table 3.1 ADSS Phase I Facility Sample Sizes, by Facility Characteristics and Availability
of Substance Abuse Treatment Programming for Women: 1996–1997
Number of Facilities with
Number of Facilities Overall Child Care Services Data
(n = 2,395 Facilities) (n = 2,390 Facilities)
Offered Did Not Offer
Women- Mixed- Child Care Child Care
Facility Characteristic Total Only Gender Services Services
Facility Type of Care
Outpatient nonmethadone only 1,083 20 1,063 161 918
Nonhospital residential only 428 64 364 51 377
Outpatient methadone only 324 2 322 30 294
Hospital inpatient only 203 — 203 2 201
Combination 357 10 347 76 280
Number of Clients
175 or more 619 1 618 117 501
75 to 174 542 7 535 81 460
25 to 74 597 18 579 55 540
24 or fewer 637 70 567 67 569
Ownership
Private, nonprofit 1,478 81 1,397 233 1,241
Private, for-profit 498 3 495 22 475
City or county government 249 7 242 47 202
State government 95 3 92 12 83
Federal government 64 1 63 2 62
Tribal government 11 1 10 4 7
Services Offered 1,2
Child care 320 54 266 320 2,070
Prenatal care 385 34 351 98 287
Transportation 1,183 87 1,096 236 945
Family counseling 1,958 77 1,881 279 1,675
Combined substance abuse treatment and
mental health services 1,252 38 1,214 177 1,071
Special Programs Offered 1,2
Women 973 88 885 250 720
Pregnant women 562 50 512 190 371
Dual-diagnosis clients 973 34 939 168 802
AIDS/HIV-positive clients 691 33 658 137 554
1
Sampled facilities for which no answer was recorded for the item about provision of a service or program are
counted as not offering the service or program.
2
Categories are not mutually exclusive.

AIDS = acquired immunodeficiency syndrome; HIV = human immunodeficiency virus.

Source: Alcohol and Drug Services Study (ADSS), Phase I data, 1996–1997. Substance Abuse and Mental Health
Services Administration, Office of Applied Studies.

47
The Phase II data contain abstracted information for 5,005 discharged substance abuse treatment
clients aged 13 or older (Table 3.2). The sample of client records was used to examine
characteristics of substance abuse treatment clients (Chapter 4). The sample of Phase I facilities
was used to examine characteristics of facilities offering substance abuse treatment programming
for women (Chapter 5). The sample for the analysis of the relationship between the gender of
clients and retention (Chapter 6) was restricted to records for clients aged 18 or older (n = 4,689
clients). This sample excludes youths younger than 18 because differences between adult and
juvenile treatment systems are significant, and the findings were intended to be generalized only
to the adult treatment system. Furthermore, differences, such as child care needs, between adults
and youths regarding treatment programming were expected. The analysis of the relationship
between substance abuse treatment programming for women and retention among women
(Chapter 6) was based on records for female clients aged 18 or older for whom retention
information was available (n = 1,239 clients).

Measures and Definitions of Terms Used in This Report

This section describes ADSS measures and provides definitions of key study variables.

Client Characteristics

A range of client demographic and background variables was included in ADSS Phase I and
Phase II data. Age of the client was defined as “age at admission.” Phase I client race/ethnicity
was reported by facilities, and Phase II client race information was abstracted from client records.
Missing data for client ethnicity precluded including this information in Phase II analyses. Phase
II data included client education at admission, primary source of referral to treatment, primary
source of payment for treatment, marital status at admission, clients’ having a child or children at
admission, employment at admission, and living arrangement at admission. Phase II gleaned data
about clients’ presenting substance abuse problem at admission and the substance of choice
specified at admission. Treatment service type (Chapter 4) was measured using ADSS Phase II
client abstract data and refers to the specific service received by each client, regardless of
whether the facility providing treatment offered more than one type of care. The three service
types are (1) outpatient nonmethadone, (2) nonhospital residential, and (3) outpatient methadone
treatment. Categories for some client demographic, background, and substance use
characteristics were collapsed for some analyses.

Components of Substance Abuse Treatment Programming for Women

Prevalence and retention estimates associated with substance abuse treatment programming for
women were based on the following facility characteristics: women-only facilities, facilities
offering child care services, facilities offering prenatal care services, facilities offering special
programs for women, and facilities offering special programs for pregnant women. Women-only
facilities referred to those with active clients on October 1, 1996, and that served only female
clients on that date. Facilities offering child care services referred to facilities offering child care
services during the most recent 12-month period for which data were available, defined as
“services that provide care for minor children of active clients, including supervised activities.”
Similarly, facilities offering prenatal care services referred to facilities offering prenatal care

48
Table 3.2 ADSS Phase II Client Sample Sizes for All Substance Abuse Treatment Clients
Aged 13 or Older, by Gender and Service Type of Care: 1997–1999
Service Type of Care
Outpatient
Nonmethadone Nonhospital Residential Outpatient Methadone
Characteristic Total Female Male Total Female Male Total Female Male
Total 3,642 939 2,703 878 198 680 463 197 266
Age at Admission (Years)
13 to 17 239 67 172 54 9 45 1 -- 1
18 to 24 562 115 447 99 19 80 24 12 12
25 to 34 1,215 347 868 290 80 210 165 79 86
35 to 44 1,069 294 775 299 63 236 183 80 103
45 to 54 372 80 292 99 15 84 73 21 52
55 or older 135 24 111 23 6 17 12 4 8
Unknown/not mentioned 50 12 38 14 6 8 5 1 4
Race
White 2,263 574 1,689 411 100 311 186 82 104
Black 763 260 503 364 75 289 126 63 63
Other 214 34 180 30 10 20 65 24 41
Unknown/not mentioned 402 71 331 73 13 60 86 28 58
Marital Status at Admission 1
Not married 2,663 724 1,939 690 149 541
Married/common law 859 183 676 152 38 114
Unknown/not mentioned 120 32 88 36 11 25
Have Child/Children at
Admission 1
Yes 1,961 648 1,313 509 149 360
No 1,117 204 913 269 38 231
Unknown/not mentioned 564 87 477 100 11 89
Living Arrangement at
Admission 1
With spouse/partner 999 251 748 124 35 89
With parent(s) 817 173 644 143 28 115
Alone 432 101 331 73 21 52
With other family 348 116 232 58 12 46
With no other adult(s)/children
only 113 85 28 10 8 2
No stable arrangement at
admission (includes
homeless, shelters) 163 46 117 185 38 147
With friends 212 46 166 35 7 28
Correctional facility 20 4 16 102 6 96
Other institution/closed facility 76 21 55 56 9 47
Unknown/not mentioned 462 96 366 92 34 58
(continued)

49
Table 3.2 ADSS Phase II Client Sample Sizes for All Substance Abuse Treatment Clients
Aged 13 or Older, by Gender and Service Type of Care: 1997–1999 (continued)

Service Type of Care

Outpatient
Nonmethadone Nonhospital Residential Outpatient Methadone
Characteristic Total Female Male Total Female Male Total Female Male
1
Education at Admission
Less than high school graduate 1,277 361 916 316 73 243
High school graduate/GED 1,301 301 1,000 299 65 234
Some college, college
graduate, or postgraduate 806 223 583 212 48 164
Unknown/not mentioned 258 54 204 51 12 39
Employment at Admission
Unemployed 1,357 471 886 596 150 446 270 113 157
Employed full time (35
hours/week or more) 1,151 166 985 104 11 93 67 19 48
Employed part time (fewer
than 35 hours/week) 279 90 189 30 6 24 30 17 13
Keeping house, not otherwise
employed 63 59 4 6 6 — 11 10 1
Employed, not otherwise
specified 326 39 287 15 2 13 24 12 12
Disabled 156 35 121 34 7 27 28 11 17
Other 116 28 88 54 6 48 3 — 3
Unknown/not mentioned 194 51 143 39 10 29 30 15 15
Primary Source of Referral for
Treatment
Criminal justice system 1,925 322 1,603 298 42 256 18 4 14
Self-referred/voluntary 553 195 358 247 70 177 264 117 147
Other treatment facility 268 81 187 114 24 90 59 30 29
Welfare office or other social
service agencies 271 124 147 57 15 42 9 4 5
Health care, mental health, or
insurance providers 230 107 123 73 25 48 25 8 17
Family/friend 163 52 111 52 13 39 37 15 22
Other 123 18 105 4 — 4 2 2 —
Unknown/not mentioned 109 40 69 33 9 24 49 17 32
Primary Expected Source of
Payment for Treatment
Client self-payment 1,367 225 1,142 214 41 173 113 43 70
Medicaid 444 216 228 58 30 28 214 88 126
Medicare or other public
funding 455 117 338 236 55 181 53 21 32
(continued)

50
Table 3.2 ADSS Phase II Client Sample Sizes for All Substance Abuse Treatment Clients
Aged 13 or Older, by Gender and Service Type of Care: 1997–1999 (continued)

Service Type of Care

Outpatient
Nonmethadone Nonhospital Residential Outpatient Methadone
Characteristic Total Female Male Total Female Male Total Female Male
Private health insurance,
fee-for-service 234 54 180 30 8 22 4 3 1
Private health insurance,
HMO/PPO/managed care 275 85 190 29 5 24 12 7 5
Criminal justice system 253 49 204 123 7 116 — — —
No payment 171 59 112 68 25 43 11 5 6
Other 57 22 35 21 5 16 12 6 6
Unknown/not mentioned 386 112 274 371 93 278 44 24 20
Presenting Substance Abuse
Problem at Admission 1
Alcohol and drug abuse 1,904 532 1,372 575 132 443
Alcohol abuse only 1,206 211 995 125 25 100
Drug abuse only (excluding
alcohol) 459 181 278 169 41 128
Unknown/not mentioned 73 15 58 9 — 9
Substance of Choice at
Admission 1
Alcohol 1,799 367 1,432 295 67 228
Cocaine 513 223 290 262 70 192
Marijuana, hashish, THC 434 88 346 71 7 64
Amphetamines 68 25 43 32 15 17
Heroin 134 35 99 84 16 68
Nontreatment methadone or
other opiates 26 17 9 11 5 6
Barbiturates, benzodiazepines,
or other sedatives or
hypnotics 13 9 4 5 2 3
Any other drug, multiple, or no
substance of choice 119 39 80 36 5 31
Unknown/not mentioned 536 136 400 82 11 71
1
Not collected for outpatient methadone clients.

GED = general equivalency diploma; HMO = health maintenance organization; PPO = preferred provider
organization; THC = tetrahydrocannabinol.

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase II client record
abstract data, 1997–1999.

51
services during the most recent 12-month period for which data were available. Facilities offering
special programs for women or special programs for pregnant women referred to those that
offered such programs on October 1, 1996.

Other Facility Characteristics

Analyses discussed in Chapters 5 and 6 grouped substance abuse treatment facilities into
categories representing five facility types of care from Phase I data: (1) outpatient nonmethadone
only, (2) nonhospital residential only, (3) outpatient methadone only, (4) hospital inpatient only,
or (5) combination facilities (i.e., those that offered more than one type of care, such as a single
treatment facility that offered residential and outpatient care).4 Analyses in Chapter 5 also
grouped facilities into categories based on the total number of active clients.

Retention

Two important constructs are used in the substance abuse treatment literature: treatment
completion and length of stay (LOS). A program or facility that has good retention is one that
generally is able to keep clients in treatment for longer periods of time. Treatment completion
means that an individual has successfully completed a treatment plan that is either generic to the
program or facility or is tailored to the client’s needs. LOS represents how long a person stays in
treatment. In Chapter 6, completion of planned treatment was 1 of 11 response options for reason
for discharge among clients in nonmethadone facilities; LOS was indicated by the number of
days between the client’s date of admission and the date of discharge in both methadone and
nonmethadone facilities.

Statistical Methods

WesVar® software (Westat, Inc., 2000) was used for descriptive analyses, incorporating
sample weights and jackknife variance estimation (Rust & Rao, 1996). In this report, a p value
less than 0.05 is considered statistically significant, except in Chapter 5 analyses of client

4
In 2002, according to the National Survey of Substance Abuse Treatment Services (N-SSATS), 81 percent
of all facilities offered outpatient care (including 7 percent that offered methadone treatment), 28 percent offered
residential care, and 8 percent offered hospital inpatient care. In addition, an estimated 90 percent of clients received
outpatient treatment (including 19 percent receiving outpatient care), 8 percent received residential care, and less
than 1 percent received hospital inpatient care (OAS, 2003b). In 1996, an estimated 76 percent of clients received
outpatient nonmethadone treatment, 14 percent received outpatient methadone care, 9 percent were in nonhospital
residential care, and 1 percent were in hospital inpatient care (OAS, 2003c). Outpatient nonmethadone facilities do
not provide methadone for treatment of dependence on heroin or other opioids and provide care in outpatient
settings; nonhospital residential facilities provide detoxification or rehabilitation in 24-hour nonhospital settings;
outpatient methadone facilities dispense methadone to treat dependence on heroin or other opioids on an outpatient
basis; and hospital inpatient facilities provide detoxification or rehabilitation services in hospital inpatient settings.
These facilities vary in the clients they serve and the approaches they use, as well as in the average LOS. In ADSS,
the average LOS for all clients discharged from treatment in the facilities studied was 133 days, or about 4.4 months
(Lee, Reif, Ritter, Levine, & Horgan, 2004). On average, outpatient methadone clients stayed in treatment longest
(mean = 520 days), followed by outpatient nonmethadone clients (mean = 144 days) and nonhospital residential
clients (mean = 45 days). Methadone treatment is typically provided over a long-term period of maintenance.
However, substantial variation exists across facilities and across studies (McLellan & McKay, 1998).

52
characteristics, special programs, and services reported by facilities. These analyses used a
Bonferroni adjustment for multiple comparisons, such that a p value less than 0.05 divided by the
number of comparisons is considered statistically significant.5 The following sections describe
the statistical methods used in this report.

Analysis of Client Characteristics

Chi-square tests were used to compare the distribution of client characteristics among
females and males (Chapter 4). Statistically significant differences were then examined using
two-sided Student’s t tests. Because the client populations of service types differed substantially,
analyses were stratified by service type of care.

Analysis of Facility Characteristics

In Chapter 5, the prevalence of substance abuse treatment programming for women was
calculated for facilities overall and for each facility type of care. For analyses in Chapter 5 of
selected client characteristics reported by facilities, an individual facility rate was calculated by
dividing the number of active clients with each characteristic (i.e., gender, race/ethnicity, age,
and payment source) by the total number of active clients for each facility based on aggregate
counts reported by facility directors in ADSS Phase I. Next, a national facility rate for each
characteristic was calculated by summing individual facility percentages and dividing by the
number of facilities with active clients reporting the characteristic. Two-sided Student’s t tests
with Bonferroni adjustment for multiple comparisons were used to examine differences in rates
for facility client variables between women-only and mixed-gender facilities and between
facilities offering child care services and those not offering such services.

Percentages of facilities with selected facility characteristics were calculated among the
numbers of women-only or mixed-gender facilities and among the numbers of facilities offering
child care services and not offering such services. Chi-square tests were used to examine
differences in facility size and ownership. Two-sided Student’s t tests were conducted to identify
the contribution of different proportions to significant chi-squares. Two-sided Student’s t tests
with Bonferroni adjustment for multiple comparisons were used to examine differences in
percentages of facilities offering services or special programs among women-only and
mixed-gender facilities and among facilities offering child care services and those not offering
such services.

Descriptive Analysis of Treatment Retention

Descriptive analyses of treatment retention in Chapter 6 used F tests to compare rates of

treatment completion or LOS among adult female and male clients and among adult female
clients at facilities with and without substance abuse treatment programming for women.

5
The Bonferroni procedure (Dunn, 1961) is designed to avoid Type I error (identifying differences that do
not really exist) by applying a more stringent criterion to determine differences between clients and facilities.

53
Different types of facilities have different treatment completion rates and different planned LOS.6
Thus, all analyses of treatment completion and LOS were stratified by facility type of care.
Two-sided Student’s t tests were conducted to identify the different proportions’ contribution to
significant F statistics.

Logistic Regression Analysis

In Chapter 6, WesVar® software (Westat, Inc., 2000) was used for the logistic regression
analysis, incorporating sample weights and jackknife variance estimation. Logistic regression
procedures were used to model completion of planned treatment as a function of clients’ gender
and, among women, treatment at women-only facilities or facilities offering child care services.
Odds ratio (OR) estimates derived from logistic regression procedures denote the estimated
magnitude of an association between a binary outcome (e.g., treatment completion) and a
covariate (e.g., client gender). An OR estimate greater than 1.00 indicates a positive association
between the outcome of interest and the covariate; an OR estimate less than 1.00 indicates an
inverse association. A 95 percent confidence interval (CI) of the OR also is presented.

Survival Analysis

SUDAAN® software (Shah, Barnwell, & Bieler, 1995) with Taylor series variance
estimation was used for the survival analyses in Chapter 6 to take into account the complex
survey design of ADSS. Survival analysis, specifically Cox’s proportional hazard regression
(Hosmer & Lemeshow, 1999; Parmar & Machin, 1995), was used to model LOS as a function of
adult clients’ gender and, among women, treatment at women-only facilities or facilities offering
child care services. Hazard ratio (HR) estimates derived from survival analysis procedures denote
the estimated magnitude of an association between a covariate (e.g., client gender) and an
outcome (e.g., discharge from treatment) over time for a defined population. An HR estimate
greater than 1.00 indicates a greater likelihood of leaving treatment earlier; a value of less than
1.00 reflects a lower likelihood of leaving treatment earlier. The HR also is presented with a CI.

Limitations of the Data

This section discusses limitations of the data source that should be considered when
interpreting analysis results.

6
Hospital inpatient facilities typically have the shortest planned LOS. Outpatient nonmethadone and
residential facilities have longer stays, and methadone treatment is typically meant to be long term. Among clients in
treatment during the early 1980s, the Treatment Outcome Prospective Study (TOPS) found the average LOS in
treatment to vary by type of care (Hubbard et al., 1989). The average number of weeks in outpatient methadone
treatment was 38.4 compared with 21.3 weeks in residential treatment and 14.6 weeks in outpatient drug-free
treatment. These averages were noted as similar to those found in the Drug Abuse Reporting Program (DARP) study
a decade earlier. Thus, when examining LOS, it is important to control for facility type; that is, LOS must be
examined only within individual facility types and not compared across facility types.

54
ADSS Phase I Data Limitations

ADSS Phase I data are based on retrospective reports by facility directors made up to 6
months after the survey point-prevalence date. Thus, these data may be subject to recall and
reporting biases. Some sources of potential bias are related to the Phase I questionnaire and
retrospective self-reports.

First, some degree of overreporting or underreporting by facility directors on the types

and numbers of clients and services may have occurred because of a lack of updated knowledge
of activities at the client or service level (TecMRKT Works, 2004), selective perception,
nonstandardized definitions of services, or a desire to represent the facility as providing more
services than it actually does. Self-report data also may be influenced by memory and recall
errors if not verified through client or service records, including recall delay (tendency to forget
events occurring long ago) or forward telescoping (tendency to report that activities occurred
more recently than they actually did). These memory errors would tend to result in estimates for
less recent data (i.e., at the beginning of the 12-month reference period) that are downwardly
biased (because of recall delay) and estimates for more recent data that are upwardly biased
(because of telescoping). However, efforts were made to minimize these sorts of biases by
requesting that facility directors check external sources of data for their responses, and attempts
were made to standardize data collection efforts across facilities through extensive training
sessions and materials for interviewers. Efforts were made to validate data through site visits and
listing/sampling of client records.

Second, in some instances, the Phase I questionnaire lacked clear definitions to describe
programs and services. For example, the Phase I questionnaire did not define “special programs”
for specific populations. It did not specify whether offering such services as child care,
transportation, or prenatal care included arrangements with other agencies to provide these
services. Thus, the validity and reliability of the responses may be limited in providing a true
estimate of service availability.

Third, there is a potential bias associated with Phase I client characteristics data
referencing a single day (October 1, 1996) if that point estimate was unrepresentative in some
way (e.g., due to seasonal variation). However, analyses of ADSS Phase I data have shown that
there is little seasonal variation.

ADSS Phase II Data Limitations

The ADSS Phase II data are based on abstraction of clinical documents by ADSS staff,
and they may be subject to additional biases. Some sources of bias are related to the abstraction
process and missing data.

First, some degree of error may have occurred because of the abstraction process. Prior
studies have shown that numerous factors may compromise data quality in record abstraction,
such as vague specification of variables or inappropriate interpretation by abstractors (Allison et
al., 2000; Peabody, Luck, Glassman, Dresselhaus, & Lee, 2000), which may be especially
challenging for mental health and substance abuse research because of the subjective nature of

55
the abstraction process (Katz, Chang, Sangha, Fossel, & Bates, 1996). Abstraction errors would
result in misclassification bias by categorizing records incorrectly and could yield an
underestimation of differences in the characteristics of clients from different groups or of
associations between substance abuse treatment programming and retention in treatment among
clients. Attempts were made to minimize this type of bias through a detailed trainer’s guide and
abstraction manual for ADSS Phase II interviewers.

Second, the Phase II client record data include fields with missing data, which may result
from poor or missing recording of information in the original chart (Allison et al., 2000; Luck,
Peabody, Dresselhaus, Lee, & Glassman, 2000). Thus, the ability to analyze some data fields is
limited.7 For example, ethnicity, pregnancy status, and information about history of psychological
disorders were more likely than other data not to be recorded in the original client chart. Missing
data are not uncommon to the medical record and record abstraction process because clinic staff
often rush through or abbreviate their paperwork duties to meet the direct needs of their clients.
In addition, the Phase II study design called for the collection of only limited information about
clients discharged from methadone treatment.8 The Appendix presents more detailed information
about missing data.

Limitations of the Analyses

The analyses presented here have important limitations, including their ability to detect
true differences between analytic groups and the lack of control for level of service utilization.
The lack of control for service intensity across facilities is probably the most important
limitation. The literature suggests that clients treated in programs that provide more services tend
to have better outcomes than clients in programs with fewer services (Broome, Simpson, & Joe,
1999; Gerstein et al., 1997; McLellan et al., 1998; Pringle et al., 2002; Smith & Marsh, 2002). As
described in Chapter 5, facilities that offered woman-focused programming were more likely to
offer more services overall than facilities not offering such programming. Therefore, when
comparisons are made between females at facilities with and without woman-focused
programming, any differences found may be the result of comparing females who received a high
level of services bundled with women-focused programming with other female treatment clients
who may have received fewer services overall. Thus, receiving treatment at facilities offering
woman-focused programming may be associated with longer stays in treatment and improved
treatment outcomes because of the high level of service intensity in such facilities.

7
Student’s t tests were used to examine study variables for significantly different amounts of missing data,
and records with missing data for a variable were excluded from analysis of that variable if there was no statistically
significant difference in the amount of missing data between groups. Where the amounts of missing data differed
significantly between the analytic groups, the missing data were included as a category and were presented in the
analysis. For example, in multivariate analyses in Chapter 6, records with missing data for a specific variable were
categorized as “not ascertained” and included in the analyses.
8
For example, information about having a child/children at admission, living arrangement at admission,
education at admission, presenting substance abuse problem at admission, and reason for discharge was not
abstracted from client records in outpatient methadone facilities.

56
 In addition, true differences may not be found or the magnitude of the differences may be
underestimated because of the low threshold of exposure to treatment required for inclusion in
ADSS. Phase II data were included in these analyses for all clients who had received at least one
treatment session, and analysis was not limited to those with a particular LOS. Thus, some
individuals coded as having received treatment may actually have received very little exposure to
programming offered by the treatment facility, and thus no effect of this programming would be
expected for these individuals. Therefore, the findings for comparisons between clients at
facilities offering substance abuse treatment programming for women and those at facilities not
offering such programming may be misleading. The findings may show no differences or
underestimate the magnitude of the difference between clients because too many individuals at
facilities offering specialized programming received an insufficient level of exposure to the
programming.

57
References

Allison, J. J., Wall, T. C., Spettell, C. M., Calhoun, J., Fargason, C. A. Jr, Kobylinski, R. W.,
Farmer, R., & Kiefe, C. (2000). The art and science of chart review. Joint Commission Journal
on Quality Improvement, 26, 115-136.

Broome, K. M., Simpson, D. D., & Joe, G. W. (1999). Patient and program attributes related to
treatment process indicators in DATOS. Drug and Alcohol Dependence, 57, 127-135.

Dunn, O. J. (1961). Multiple comparisons among means. Journal of the American Statistical
Association, 56, 52-64.

Gerstein, D. R., Datta, A. R., Ingels, J. S., Johnson, R. A., Rasinski, K. A., Schildhaus, S., Talley,
K., Jordan, K., Phillips, D. B., Anderson, D. W., Condelli, W. G., & Collins, J. S. (1997, March).
NTIES: The National Treatment Improvement Evaluation Study final report. Retrieved August 6,
2004, from http://www.icpsr.umich.edu/SAMHDA/NTIES/NTIES-PDF/ntiesfnl.pdf

Hosmer, D. Jr., & Lemeshow, S. (1999). Applied survival analysis: Regression modeling of time
to event data. New York: Wiley.

Hubbard, R. L., Marsden, M. E., Rachal, J. V., Harwood, H. J., Cavanaugh, E. R., & Ginzburg,
H. M. (1989). Drug abuse treatment: A national study of effectiveness. Chapel Hill, NC:
University of North Carolina Press.

Katz, J. N., Chang, L. C., Sangha, O., Fossel, A. H., & Bates, D. W. (1996). Can comorbidity be
measured by questionnaire rather than medical record review? Medical Care, 34, 73-84.

Lee, M. T., Reif, S., Ritter, G. A., Levine, H. J., & Horgan, C. M. (2004). Alcohol and Drug
Services Study (ADSS) Phase II: Client record abstract report (DHHS Publication No. SMA
04-3974, Analytic Series No. A-27). Rockville, MD: Substance Abuse and Mental Health
Services Administration. [Available as a PDF at http://www.oas.samhsa.gov/analytic.htm and
http://www.oas.samhsa.gov/adss.htm]

Luck, J., Peabody, J. W., Dresselhaus, T. R., Lee, M., & Glassman, P. (2000). How well does
chart abstraction measure quality? A prospective comparison of standardized patients with the
medical record. American Journal of Medicine, 108, 642-649.

McLellan, A. T., Hagan, T. A., Levine, M., Gould, F., Meyers, K., Bencivengo, M., & Durell, J.
(1998). Supplemental social services improve outcomes in public addiction treatment. Addiction,
93, 1489-1499.

McLellan, A. T., McKay, J. R. (1998). The treatment of addiction: What can research offer
practice? In S. Lamb, M. R. Greenlick, & D. McCarthy (eds.), Bridging the gap between practice
and research: Forging partnerships with community-based drug and alcohol treatment (pp. 147-
185). Washington, DC: National Academy Press.

58
Office of Applied Studies. (2002, June). Alcohol and Drug Services Study, 1996-1999 [United
States]: Phase I facility questionnaire (Part 1) [Computer file] (ICPSR 3088, conducted by
Brandeis University, 2nd ICPSR ed.). Ann Arbor, MI: Inter-university Consortium for Political
and Social Research [producer and distributor]. [Available as a PDF at
http://www.oas.samhsa.gov/adss.htm and
http://www.oas.samhsa.gov/ADSS/ADSS1FacilityQN.pdf]

Office of Applied Studies. (2003a). Alcohol and Drug Services Study (ADSS): Methodology
report: Phases I, II, and III. Rockville, MD: Substance Abuse and Mental Health Services
Administration. [Available as a PDF at http://www.oas.samhsa.gov/adss.htm]

Office of Applied Studies. (2003b). Alcohol and Drug Services Study (ADSS): The national
substance abuse treatment system: Facilities, clients, services, and staffing. Rockville, MD:
Substance Abuse and Mental Health Services Administration. [Available as a PDF at
http://www.oas.samhsa.gov/adss.htm]

Office of Applied Studies. (2003c). National Survey of Substance Abuse Treatment Services
(N-SSATS): 2002. Data on substance abuse treatment facilities (DHHS Publication No. SMA
03-3777, Drug and Alcohol Services Information System Series S-19). Rockville, MD:
Substance Abuse and Mental Health Services Administration. [Available at
http://www.oas.samhsa.gov/dasis.htm#nssats2]

Parmar, M., & Machin, D. (1995). Survival analysis: A practical approach. New York: Wiley.

Peabody, J. W., Luck, J., Glassman, P., Dresselhaus, T. R., & Lee, M. (2000). Comparison of
vignettes, standardized patients, and chart abstraction: A prospective validation study of 3
methods for measuring quality. Journal of the American Medical Association, 283, 1715-1722.

Pringle, J. L., Edmondston, L. A., Holland, C. L., Kirisci, L., Emptage, N. P., Balavage, V. K.,
Ford, W. E., Etheridge, R. M., Hubbard, R. L., Jungblut, E., & Herrell, J. M. (2002). The role of
wrap around services in retention and outcome in substance abuse treatment: Findings from the
Wrap Around Services Impact Study. Addictive Disorders & Their Treatment, 1(4), 109–118.

Rust, K. F., & Rao, J. N. (1996). Variance estimation for complex surveys using replication
techniques. Statistical Methods in Medical Research, 5, 283-310.

Shah, B. V., Barnwell, B. G., & Bieler, G. S. (1995). SUDAAN®: Software for the analysis of
correlated data, Release 6.4 [Computer software and manual]. Research Triangle Park, NC:
Research Triangle Institute.

Smith, B. D., & Marsh, J. C. (2002). Client-service matching in substance abuse treatment for
women with children. Journal of Substance Abuse Treatment, 22, 161-168.

TecMRKT Works [Oregon, WI]. (2004). Data collection techniques. Retrieved August 7, 2004,
from http://www.tecmrkt.com/paps_data_collection_tech_frameset.htm

59
Westat, Inc. (2000). WesVar® 4.0 [Computer software and manual]. Rockville, MD: Author.
[Also see http://www.westat.com/wesvar/]

60
 Chapter 4. Characteristics of Substance
Abuse Treatment Clients

Using ADSS Phase II data, this chapter compares sociodemographic characteristics of

female and male clients discharged from substance abuse treatment facilities (i.e., completed
treatment, dropped out, or were asked to leave) during a 6-month period in 1996. These
characteristics include age, race, marital status, having a child/children, living arrangement,
education, and employment at admission, as well as primary source of referral for this treatment,
primary expected source of payment for this treatment, presenting substance abuse problem at
admission, and substance of choice at admission. Because client populations receiving individual
service types differ substantially in their characteristics (e.g., age and severity of problems),
analyses were stratified by service type of care (outpatient nonmethadone, nonhospital
residential, and outpatient methadone). All results are weighted estimates based on data from
clients discharged from treatment. Although estimates are based on a 6-month data collection
period, estimated annual numbers of discharges are presented for comparisons.

Among clients discharged from outpatient nonmethadone, nonhospital residential, and

outpatient methadone treatment, females and males were similar on age at admission and race
(Table 4.1). However, female clients were generally more likely than male clients to have a
child/children at admission (Figure 4.1).

Clients discharged from outpatient nonmethadone treatment exhibited additional gender

differences:

! Females were more likely than males to live with no other adult(s)/children only
and were less likely to live with friends.

! At admission, females were more likely than males to be unemployed and were
less likely to be employed full-time (Figure 4.2).

! The primary source of referral for treatment was less likely to be the criminal
justice system, and more likely to be a welfare office or other social services
agencies, among females than males.

! The primary expected source of payment for treatment was more likely to be
Medicaid among females than males (Figure 4.3).

! The presenting substance abuse problem was less likely to be alcohol abuse only,
and more likely to have been drug abuse only, among females than males.

! Alcohol was less likely to be the substance of choice at admission among females
than males.

61
 Table 4.1 Percentages of Clients with Different Characteristics Discharged from Substance Abuse Treatment, by Treatment
Service Type and Gender: 1997–1999
Service Type of Care
Outpatient Nonmethadone Nonhospital Residential Outpatient Methadone
Female Male Female Male Female Male
Estimated Annual Number of Discharges 352,922 1,049,099 160,253 537,572 51,420 66,672
Characteristic Percent Percent Percent
Age at Admission (Years)
13 to 17 1 7.8 6.2 7.3 6.3 — *
18 to 24 13.6 16.4 10.2 11.2 6.6 3.6
25 to 34 36.5 31.4 34.0 33.2 42.9 31.1
35 to 44 26.8 29.7 33.1 33.6 40.3 40.6
45 to 54 12.0 11.0 11.7 12.1 10.0 21.4
55 or older 3.4 5.3 3.7 3.5 * 2.7
Race
White 74.1 78.1 62.8 60.4 51.8 54.8
Black 22.6 16.0 32.0 35.8 36.7 30.3
American Indian, Alaska Native, Asian or Pacific Islander 3.3 5.9 5.3 3.8 11.5 14.9

62
Marital Status at Admission 2
Never married, widowed, separated/divorced, single,
unknown/not mentioned, or other 73.9 70.3 73.5 80.1
Married/common law 26.1 29.7 26.5 19.9
Have Child/Children at Admission 2,3,4
Yes 67.6 51.1 72.6 55.2
No 22.9 31.5 24.7 32.6
Unknown/not mentioned 9.5 17.4 2.7 12.2
Living Arrangement at Admission 2,3
With spouse/partner 35.3 34.6 29.4 20.8
With parent(s) 20.9 22.8 23.0 22.0
Alone 11.9 15.4 14.6 14.1
With other family 12.2 8.9 8.2 8.8
With no other adult(s)/children only 10.4 1.3 5.8 *
No stable arrangement (includes homeless and shelters) 3.2 6.4 11.2 16.6
With friends 3.5 7.9 4.3 3.7
Correctional facility * 0.9 2.8 9.0
Other institution/closed facility 2.4 1.8 0.8 4.5
(continued)
 Table 4.1 Percentages of Clients with Different Characteristics Discharged from Substance Abuse Treatment, by Treatment
Service Type and Gender: 1997–1999 (continued)
Service Type of Care
Outpatient Nonmethadone Nonhospital Residential Outpatient Methadone
Female Male Female Male Female Male
Estimated Annual Number of Discharges 352,922 1,049,099 160,253 537,572 51,420 66,672
Characteristic Percent Percent Percent
2
Education at Admission
Less than high school graduate (not otherwise specified),
8–11 years, or fewer than 8 years 39.2 33.8 40.0 35.8
High school graduate/GED 34.3 40.8 33.1 41.7
Some college, college graduate, or postgraduate 26.5 25.4 26.9 22.5
Employment at Admission 5
Unemployed 47.6 32.7 69.6 55.4 58.2 60.2
Employed full time (35 hours/week or more) 25.9 40.3 10.1 22.1 9.4 18.9
Employed part time (fewer than 35 hours/week) 8.2 6.7 5.0 4.2 9.3 5.1
Keeping house, not otherwise employed 7.5 * 3.7 — 3.7 *
Employed, not otherwise specified 4.9 12.0 * 2.3 12.3 5.3

63
Disabled 2.0 4.2 5.7 7.6 7.1 7.2
Retired, inmate, or unknown/not mentioned 3.9 4.0 4.7 8.4 — *
Primary Source of Referral for Treatment 3
Criminal justice system 39.4 57.0 24.1 35.2 * 9.1
Self-referred/voluntary 22.1 15.4 36.5 32.9 71.1 62.0
Other treatment facility 10.7 7.3 11.5 11.1 12.1 12.4
Welfare office or other social service agencies 11.3 4.2 6.4 4.6 * 1.4
Health care, mental health, or insurance providers 8.5 4.9 10.7 9.6 1.9 4.4
Family/friend 6.2 5.4 10.9 5.6 8.7 10.7
Employer or unknown/not mentioned 1.7 5.9 — * * —
Primary Expected Source of Payment for Treatment 3
Client self-payment 34.7 44.1 30.6 40.1 28.9 35.7
Medicaid 20.1 5.8 23.9 8.6 39.2 37.2
Medicare or other public funding 8.6 10.0 45.4 44.4 16.9 16.9
Private health insurance, fee-for-service 9.4 10.4 15.5 12.5 * *
Private health insurance, HMO/PPO/managed care 8.5 7.6 14.9 10.5 2.9 2.0
Criminal justice system 9.8 12.7 11.8 23.4 — —
No payment 6.7 7.5 5.7 4.3 1.6 3.0
Not permitted to abstract or unknown 2.2 1.9 6.7 4.8 8.0 5.0
(continued)
 Table 4.1 Percentages of Clients with Different Characteristics Discharged from Substance Abuse Treatment, by Treatment
Service Type and Gender: 1997–1999 (continued)
Service Type of Care
Outpatient Nonmethadone Nonhospital Residential Outpatient Methadone
Female Male Female Male Female Male
Estimated Annual Number of Discharges 352,922 1,049,099 160,253 537,572 51,420 66,672
Characteristic Percent Percent Percent
2,3
Presenting Substance Abuse Problem at Admission
Alcohol and drug abuse 53.7 53.3 60.1 63.3
Alcohol abuse only 27.2 38.5 19.4 21.3
Drug abuse only (excluding alcohol) 19.1 8.2 20.5 15.4
Substance of Choice at Admission 2,3
Alcohol 49.4 63.4 40.5 45.8
Cocaine 19.2 11.3 32.3 23.6
Marijuana, hashish, THC 14.2 16.2 4.7 10.9
Amphetamines 4.5 2.5 4.8 4.6
Heroin 2.3 2.9 7.9 9.5
Nontreatment methadone or other opiates 4.9 0.2 5.3 0.6

64
Barbiturates, benzodiazepines, or other sedatives or hypnotics 0.9 * * *
Any other drug, multiple, or no substance of choice 4.7 3.4 3.5 4.9
* Low precision; no estimate reported.

– Not available.

1
Persons under age 18 are generally not eligible for methadone treatment.
2
Not collected for outpatient methadone clients.
3
Difference between female and male estimates is statistically significant at the 0.05 level among clients discharged from outpatient nonmethadone treatment.
4
Difference between female and male estimates is statistically significant at the 0.05 level among clients discharged from residential nonmethadone treatment.
5
Difference between female and male estimates is statistically significant at the 0.001 level among clients discharged from outpatient nonmethadone treatment.

GED = general equivalency diploma; HMO = health maintenance organization; PPO = preferred provider organization; THC = tetrahydrocannabinol.

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase II client data, 1997–1999.
Figure 4.1 Percentages of Substance Abuse Treatment Clients Having a Child/Children at
Admission, by Gender and Service Type: 1997–1999

100 2.7
9.5 12.2
17.4
24.7
22.9
80 32.6
31.5

60
67.6 72.6
51.1 55.2

40

20

0
Female Male Female Male
Outpatient Nonmethadone Treatment Residential Nonmethadone Treatment

Have a Child/Children at Admission

Do Not Have a Child/Children at Admission
Unknown/Not Mentioned

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase II client data,
1997–1999.

Figure 4.2 Percentages of Employment at Admission among Substance Abuse Treatment

Clients Discharged from Outpatient Nonmethadone Treatment, by Gender:
1997–1999

Note: Small sample sizes prevented analyses of outpatient nonmethadone clients keeping house, not otherwise
employed.

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase II client data,
1997–1999.

65
Figure 4.3 Percentages of Primary Source of Payment for Treatment among Substance
Abuse Treatment Clients Discharged from Outpatient Nonmethadone
Treatment, by Gender: 1997–1999

50
Female Male
44.1

40
34.7

30

20.1 20.3
20 18.3

12.7
10.0 9.8
10 8.6
7.5
5.8 6.7

2.2 1.9
0
Medicaid Private Insurance No Payment
Client Medicare/Other Criminal Justice Not Permitted to Abstract,
Self-Pay Public System Unknown, or Other

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase II client data,
1997–1999.

Summary

Although female and male clients generally were similar on race and age at admission to
treatment, females were more likely to have a child/children at admission than males. There were
important gender differences in economic status among clients discharged from outpatient
nonmethadone treatment, including lower levels of employment and higher rates of Medicaid
payment for treatment among females than males. Compared with males, females discharged
from outpatient methadone treatment were also more likely to be admitted for drug abuse instead
of alcohol abuse.

66
 Chapter 5. Characteristics of Substance Abuse Treatment
Facilities Providing Treatment Programming for Women

This chapter presents estimates of the percentages of female clients in substance abuse
treatment facilities, the availability of substance abuse treatment programming for women, and
comparisons between facilities treating women only and those that treat both women and men.
These estimates are based on Alcohol and Drug Services Study (ADSS) Phase I data, which are
from facility directors’ or administrators’ reports on facility characteristics. Phase I data also
include facility directors’ or administrators’ reports of the number and type of active clients on a
reference date of October 1, 1996. After calculating each facility’s percentage of female clients,
national female-client rates were determined by summing facility percentages and dividing by the
number of facilities with active clients, across all facilities and by type of care.

The prevalence of substance abuse treatment programming designed specifically for women
also was examined, focusing on the following components: women-only treatment, child care
services, prenatal care services, and special programs offered to women or pregnant women.
Respondents were asked whether facilities offered services to any substance abuse clients during
the most recent 12-month period for which client data were available and whether any special
programs were offered to specific types of clients. Differences in the characteristics of facilities
treating women only and facilities treating both women and men also were examined, based on
ADSS Phase I questions on the number of active female clients. Facilities were classified as
women-only if 100 percent of their active clients were female on the reference date. Finally,
characteristics of facilities offering child care services were compared with those of facilities not
offering child care services.

Female Clients in Substance Abuse Treatment Facilities

According to facility administrators’ reports, 32 percent of clients were female in substance

abuse treatment facilities across the nation (Figure 5.1). The percentage of female clients varied
across types of care. Almost 30 percent of clients were female in outpatient nonmethadone
facilities, the most common type of care; in comparison, 39 percent of outpatient methadone
clients were female.

Availability of Substance Abuse Treatment Programming for Women

Table 5.1 presents estimates of availability of substance abuse treatment programming for
women. Almost 6 percent of all facilities served only female clients:

! Women-only treatment availability ranged from about 2 percent of outpatient

nonmethadone facilities to 21 percent of nonhospital residential facilities.

! No hospital inpatient facilities in the ADSS Phase I sample served only females.

67
Figure 5.1 Percentages of Female Clients in Substance Abuse Treatment Facilities, by
Facility Type of Care: 1996–1997
50

40 39.4
36.1
34.3
31.9
29.8
30
26.6

20

10

0
Outpatient Nonmethadone Only Outpatient Methadone Only Combination
Facilities Overall Nonhospital Residential Only Hospital Inpatient Only
Facility Type of Care

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase I data,
1996–1997.

Services

Overall, 13 percent of facilities offered child care services, including 15 percent of

nonhospital residential facilities, 13 percent of outpatient nonmethadone facilities, and 8 percent
of outpatient methadone facilities. Almost 12 percent of facilities overall offered prenatal care
services: 6 percent of outpatient nonmethadone facilities, 19 percent of nonhospital residential or
outpatient methadone facilities, and 33 percent of hospital inpatient facilities.

Special Programs

Overall, a little more than one third of facilities nationwide offered special programs for
women, and 19 percent offered special programs for pregnant women:

! Nonhospital residential facilities and outpatient methadone facilities were most

likely to provide special programs for women (43 percent each).

! Hospital inpatient facilities were least likely to offer special programs for women
(19 percent).

! Outpatient methadone facilities were most likely to offer special programs for
pregnant women (39 percent).

! Hospital inpatient facilities were least likely to offer special programs for pregnant
women (13 percent).

68
Table 5.1 Percentages of Substance Abuse Treatment Facilities Offering Substance
Abuse Treatment Programming for Women, Overall and by Facility Type of
Care: 1996–1997
Facility Type of Care
Outpatient
Facilities Non- Nonhospital Outpatient Hospital Combination
Overall methadone Residential Methadone Inpatient Types of Care
Facility N = 12,387 N = 7,524 N = 2,135 N = 464 N = 378 N = 1,886
Characteristic n = 2,395 n = 1, 083 n = 428 n = 324 n = 203 n = 357
Women-Only
Facilities 1 5.9 2.2 21.0 * * 6.2
Child Care
Services 2 13.3 12.7 15.4 7.8 * 17.0
Prenatal Care
Services 2 11.9 5.7 19.1 19.0 32.6 22.8
Special Programs
for Women 2 37.4 36.3 42.8 42.7 19.0 38.0
Special Programs
for Pregnant
Women 2 19.3 17.0 21.4 39.4 12.6 22.7
* Low precision; no estimate reported.
N = Estimated number of facilities with active clients in the United States; N excludes facilities with no clients in
treatment for substance abuse on October 1, 1996.
n = Number of facilities sampled with active clients; n excludes facilities with no clients in treatment for
substance abuse on October 1, 1996.
1
Facilities with no active clients on October 1, 1996, were not counted as women-only facilities.
2
Sampled facilities that did not report whether they offered a service or special program were not counted as
offering the service or special program.

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase I data,
1996–1997.

Comparisons between Women-Only and Mixed-Gender Facilities

Women-only and mixed-gender facilities exhibited many differences (Table 5.2):

! Compared with mixed-gender facilities, women-only facilities served higher

proportions of black clients.

! The proportion of clients aged 35 or older was lower at women-only facilities

compared with mixed-gender facilities.

! Rates for client self-payment, private health insurance, or Medicare were lower
among women-only facilities compared with mixed-gender facilities.

! The rate for public payment other than Medicaid or Medicare was higher among
women-only than mixed-gender facilities.

69
 ! Women-only facilities were more likely to serve a smaller number of active
clients compared with mixed-gender facilities.

In addition, women-only facilities were more likely than mixed-gender facilities to offer
women’s programming, such as child care services, prenatal care services, transportation
services, special programs for women, and special programs for pregnant women.

Comparisons between Facilities with and without Child Care Services

Table 5.3 presents estimates of facilities offering child care services and those not
offering child care services. Compared with facilities that did not offer child care services, those
that offered these services treated higher proportions of female clients and clients for whom
Medicaid was the primary source of payment. The distribution of client race/ethnicity was similar
among facilities with and without child care services.9 The rate for HMO/PPO/managed care
private health insurance was lower among facilities with child care services than among facilities
without these services.

Facilities offering child care services were more likely to be larger facilities, and were
more likely to offer other women’s programming (such as prenatal care services, transportation
services, special programs for women, and special programs for pregnant women) than facilities
that did not offer child care services. In addition, facilities with child care services were more
likely to offer special programs for dual-diagnosis clients or AIDS/HIV-positive clients than
facilities without child care services.

Facilities offering child care services were more likely to be larger facilities, and were
more likely to offer other women’s programming (such as prenatal care services, transportation
services, special programs for women, and special programs for pregnant women), than facilities
that did not offer child care services. In addition, facilities with child care services were more
likely to offer special programs for dual-diagnosis clients or AIDS/HIV-positive clients than
facilities without child care services.

9
Note that p < 0.01 (0.05 divided by 5 comparisons for Bonferroni adjustment) is statistically significant.

70
Table 5.2 National Facility Rates (NFRs) and Percentages for Selected Substance Abuse
Treatment Facility Characteristics, by Facility Clientele Composition:
1996–1997
Facility Clientele Composition
Women-Only Facilities Mixed-Gender Facilities
N = 733 N = 11,562
n = 96 n = 2,281
Characteristic NFR NFR
Race/Ethnicity
White, not Hispanic 1 43.1 62.1
Black, not Hispanic 1 36.4 22.2
Hispanic 13.8 9.5
Asian or Pacific Islander 1.3 0.8
American Indian or Alaska Native 4.3 2.4
Unknown 1.1 2.9
Age at Admission (Years)
Younger than 18 9.4 11.5
18 to 24 2 25.7 13.4
25 to 34 1 41.9 31.5
35 to 44 2 19.2 26.9
45 or older 1 2.8 12.2
Unknown 2 1.1 4.5
Primary Expected Source of Payment
No payment 7.1 7.5
Client self-payment 2 13.3 23.7
Private health insurance, fee-for-service 1 0.4 9.9
Private health insurance, HMO/PPO/managed care 1 1.4 10.7
Medicaid 20.2 14.6
Medicare 1 0.1 3.8
Other public payment 1 55.0 26.9
Unknown 2.3 3.0
Percent Percent
1
Number of Clients
175 or more * 14.2
75 to 174 6.3 20.6
25 to 74 11.5 32.5
24 or fewer 81.4 32.7
(continued)

71
Table 5.2 National Facility Rates (NFRs) and Percentages for Selected Substance Abuse
Treatment Facility Characteristics, by Facility Clientele Composition:
1996–1997 (continued)
Facility Clientele Composition
Women-Only Facilities Mixed-Gender Facilities
N = 733 N = 11,562
n = 96 n = 2,281
Characteristic Percent Percent
4
Services Offered
Child care 1 55.5 10.6
Prenatal care 1 39.9 10.1
Transportation 1 92.8 46.6
Family counseling 76.8 86.1
Combined substance abuse treatment and mental
health services 3 41.1 55.2
Special Programs Offered 4
Women 1 91.0 34.0
Pregnant women 1 54.6 17.1
Dual-diagnosis clients 37.0 40.5
AIDS/HIV-positive clients 30.1 21.2
Note: NFRs were calculated by summing individual facility percentages and dividing by the number of facilities
with active clients reporting each client characteristic.
* Low precision; no estimated reported.
Degrees of freedom = 200.
N = Estimated number of facilities with active clients in the United States; N excludes facilities with no clients in
treatment for substance abuse on October 1, 1996.
n = Number of facilities sampled with active clients; n excludes facilities with no clients in treatment for substance
abuse on October 1, 1996.
1
Difference between women-only and mixed-gender facility estimates is statistically significant at the 0.001 level.
2
Difference between women-only and mixed-gender facility estimates is statistically significant at the 0.01 level.
3
Difference between women-only and mixed-gender facility estimates is statistically significant at the 0.05 level.
4
Sampled facilities for which no answer was recorded for the item about provision of a service or program are
counted as not offering the service or program. Estimates are affected accordingly. Categories are not mutually
exclusive.

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase I data, 1996–1997.

72
Table 5.3 National Facility Rates (NFRs) and Percentages for Selected Substance Abuse
Treatment Facility Characteristics, by Availability of Child Care Services:
1996–1997
Facilities Offering Facilities Not Offering
Child Care Services Child Care Services
N = 1,621 N = 10,605
n = 318 n = 2,054
Characteristic NFR NFR
Gender
Female 1 51.3 29.0
Male 1 47.6 69.9
Unknown 1.1 1.1
Race/Ethnicity
White, not Hispanic 56.9 61.6
Black, not Hispanic 2 28.3 22.3
Hispanic 9.1 9.9
Asian or Pacific Islander 0.5 0.9
American Indian or Alaska Native 3.3 2.4
Unknown 1.8 3.0
Age at Admission (Years)
Younger than 18 8.2 11.9
18 to 24 3 18.4 13.5
25 to 34 1 37.7 31.4
35 to 44 23.7 26.7
45 or older 1 8.9 12.1
Unknown 3.0 4.4
Primary Expected Source of Payment
No payment 8.3 7.3
Client self-payment 21.0 23.5
Private health insurance, fee-for-service 2 6.4 9.8
Private health insurance, HMO/PPO/managed care 1 5.1 10.5
Medicaid 3 22.8 13.8
Medicare 2.2 3.8
Other public payment 31.7 28.3
Unknown 2.5 3.0
Percent Percent
1
Number of Clients
175 or more 23.2 11.9
75 to 174 24.8 19.1
25 to 74 22.5 32.8
24 or fewer 29.6 36.2
(continued)

73
Table 5.3 National Facility Rates (NFRs) and Percentages for Selected Substance Abuse
Treatment Facility Characteristics, by Availability of Child Care Services:
1996–1997 (continued)
Facilities Offering Child Facilities Offering Child
Care Services Care Services
N = 1,643 N = 10,676
n = 320 n = 2,070
Characteristic Percent Percent
4
Services Offered
Prenatal care 1 30.8 9.1
Transportation 1 78.1 45.2
Family counseling 83.1 85.9
Combined substance abuse treatment and mental
55.5 53.9
health services
Special Programs Offered 4
Women 1 78.6 31.1
3
Pregnant women 57.2 13.5
Dual-diagnosis clients 3 50.9 38.8
3
AIDS/HIV-positive clients 35.3 19.8
Note: National facility rates (NFRs) were calculated by summing individual facility percentages and dividing by the
number of facilities with active clients reporting each client characteristic.
* Low precision; no estimate reported.
Degrees of freedom = 200.
N = Estimated number of facilities with active clients in the United States; N excludes facilities with no clients in
treatment for substance abuse on October 1, 1996.
n = Number of facilities sampled with active clients; n excludes facilities with no clients in treatment for substance
abuse on October 1, 1996.
1
Difference between estimates for facilities offering child care services and those not offering such services is
statistically significant at the 0.001 level.
2
Difference between estimates for facilities offering child care services and those not offering such services is
statistically significant at the 0.05 level.
3
Difference between estimates for facilities offering child care services and those not offering such services is
statistically significant at the 0.01 level.
4
Sampled facilities for which no answer was recorded for the item about provision of a service or program are
counted as not offering the service or program. Estimates are affected accordingly. Categories are not mutually
exclusive.

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase I data, 1996–1997.

74
Summary

The availability of substance abuse treatment programming for women varied by type of
facility:

! Outpatient nonmethadone facilities were less likely than facilities overall to treat
women only or offer prenatal services and were equally as likely as other facility
types to offer child care services, special programs for women, or special
programs for pregnant women.

! Nonhospital residential facilities were most likely to serve women only and were
more likely than other types of care to offer child care services, prenatal care
services, or special programs for women or for pregnant women.

! Outpatient methadone facilities were most likely to offer special programs for
women or pregnant women, but few offered child care services.

! Hospital inpatient facilities did not serve women only, were the most likely of all
types of care to offer prenatal care services, and were least likely to offer special
programs for women or pregnant women.

Comparisons of types of facilities revealed the following findings:

! Compared with mixed-gender facilities, women-only facilities were smaller; were

less likely to serve clients with private health insurance or whose primary source
of payment was self-pay; and were more likely to offer child care, prenatal care, or
transportation services.

! Compared with facilities not offering child care services, facilities offering these
services were larger; were more likely to serve female clients; and were more
likely to offer other women-oriented programming, such as prenatal care services,
transportation services, special programs for women, or special programs for
pregnant women.

75
76
 Chapter 6. Retention in Substance Abuse Treatment:
Gender and Substance Abuse Treatment Programming
for Women
This chapter presents findings on (1) gender differences in LOS and completion of
planned substance abuse treatment and (2) differences in LOS and treatment completion among
females at facilities with and without substance abuse treatment programming specifically for
women. Data in this chapter about client and organizational factors associated with retention can
potentially inform approaches to treatment efforts and also may improve understanding of the
underlying factors affecting treatment retention. First, percentages of clients’ reasons for
discharge from substance abuse treatment (including treatment completion) were calculated.
Mean LOS by facility type of care was also estimated. Next, gender differences in completion of
planned treatment and LOS were examined using Alcohol and Drug Services Study (ADSS)
Phase I and II data. Analyses of LOS included Phase II data for female and male clients aged 18
or older discharged from outpatient nonmethadone, nonhospital residential, or combination
facilities. Phase I data were used to identify facility type of care. Because data about reason for
discharge were not abstracted from Phase II client records at outpatient methadone facilities,
analyses of treatment completion did not include clients discharged from outpatient methadone
facilities. Analyses also focus on two components of substance abuse treatment programming for
women: women-only treatment and child care services. Differences in treatment retention were
examined among (1) clients at women-only facilities and women at mixed-gender facilities and
(2) women at facilities offering child care services and at facilities not offering child care
services. Phase I data were used to identify facility characteristics.

Descriptive analyses are presented first, followed by multivariate analyses. Logistic

regression procedures were used to determine the relationship between gender or substance abuse
treatment programming for women and completion of planned treatment. Survival analysis
procedures were used to determine the relationship between gender or substance abuse treatment
programming for women and LOS. Multivariate analyses controlled for additional client and
organizational characteristics associated with retention.

Descriptive Analyses

Among adult clients discharged from outpatient nonmethadone, nonhospital residential,

or combination facilities, 54 percent completed planned treatment (Figure 6.1). Mean LOS varied
by facility type of care (Figure 6.2).

At outpatient nonmethadone or nonhospital residential facilities, women were less likely

to complete planned treatment than were men (Table 6.1). Among adult clients at facilities
providing a combination of types of care, women were more likely to complete planned treatment
than were males. At facilities providing nonhospital residential treatment, women averaged
shorter stays in treatment than did men (Table 6.2). Women averaged longer stays in treatment
than did men at facilities providing other types of care, although these differences were not
statistically significant.

77
Figure 6.1 Percentages of Reasons for Discharge among Substance Abuse Treatment
Clients Aged 18 or Older: 1997–1999

Completed Planned Treatment 54.3

Did Not Complete Treatment 25.2

by Client Choice

Did Not Complete Treatment by 8.4

Administration Choice

Did Not Complete Treatment, Referred/

Transferred to Another Program
6.1

Did Not Complete

Treatment, Incarcerated 1.2

Did Not Complete Treatment,

No Payment Source 0.5

Did Not Complete Treatment, 0.1

Insurance Benefits Expired

Did Not Complete Treatment, 0.4

Not Otherwise Specified

Other 1.3

Unknown/Not Mentioned
2 .2

0 10 20 30 40 50 60
Percent

Note: Analysis of client deceased as reason for discharge could not be conducted because of small sample size.

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase II client data,
1997–1999.

Rates of treatment completion were similar among clients at women-only facilities and
among women at mixed-gender nonhospital residential facilities (Table 6.3).10 At facilities
providing nonhospital residential treatment, clients at women-only facilities stayed in treatment
longer than women at mixed-gender facilities (Table 6.4). However, at facilities providing a
combination of types of care, clients at women-only facilities remained in treatment for shorter
stays than women at mixed-gender facilities. Rates of treatment completion were lower among
women at facilities offering child care services than among women at facilities not offering these
services, although these differences were not statistically significant (Table 6.5). At nonhospital
residential facilities, women stayed in treatment longer at facilities offering child care services
than did women at facilities without child care services (Table 6.6).

10
Differences in treatment completion among women-only and mixed-gender outpatient nonmethadone or
combination facilities could not be analyzed because of small sample sizes or because one of the strata contained
only one primary sampling unit.

78
Figure 6.2 Average Length of Stay (LOS), in Days, of Substance Abuse Treatment
Clients Aged 18 or Older, by Facility Type of Care: 1997–1999
500 481.7

400

300

200
147.4

100 93.5
54.6

0
Nonhospital Residential Combination
Outpatient Nonmethadone Outpatient Methadone
Facility Type of Care

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase II client data,
1997–1999.

Table 6.1 Completion of Planned Treatment among Substance Abuse Treatment Clients
Aged 18 or Older at Admission, by Gender and Facility Type of Care
Gender
Women Men
Number Completing Number Completing
Facility Type of Care Planned Treatment Percent Planned Treatment Percent
1
Outpatient nonmethadone 110,678 46.0 393,364 53.1
2
Nonhospital residential 42,803 60.4 176,250 68.2
2
Combination 80,201 62.3 236,851 54.6
1
Difference between estimate for women and estimate for men is statistically significant at the 0.05 level.
2
Difference between estimate for women and estimate for men is statistically significant at the 0.01 level.

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase I data
(1996–1997) and Phase II data (1997–1999).

79
Table 6.2 Length of Stay (LOS), in Days, among Substance Abuse Treatment Clients Aged
18 or Older at Admission, by Gender and Facility Type of Care
Gender
Women Men
Number of Average LOS Number of Average LOS
Facility Type of Care Clients (in Days) Clients (in Days)
Outpatient nonmethadone 247,607 153.8 754,556 145.4
1
Nonhospital residential 72,325 34.0 264,029 60.5
Outpatient methadone 36,269 531.4 53,173 447.8
Combination 147,976 146.7 454,697 76.2
1
Difference between LOS of women and LOS of men is statistically significant at the 0.001 level.

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase I data
(1996–1997) and Phase II data (1997–1999).

Table 6.3 Completion of Planned Treatment among Female Substance Abuse Treatment
Clients Aged 18 or Older at Admission, by Facility Clientele Composition and
Facility Type of Care
Facility Clientele Composition
Women-Only Facilities Mixed-Gender Facilities
Number of Clients Number of Women
Completing Planned Completing Planned
Facility Type of Care Treatment Percent Treatment Percent
Outpatient nonmethadone % % 110,266 46.3
Nonhospital residential 8,898 65.2 33,905 59.3
Combination 165 13.9 80,036 62.7
*Low precision; no estimate reported.

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase I data
(1996–1997) and Phase II data (1997–1999).

Logistic Regression Models

Gender was not associated with completion of planned treatment, after controlling for
other client and facility characteristics (Table 6.7). Control variables associated with treatment
completion were education at admission, primary source of referral for treatment, primary
expected source of payment for treatment, and facility type of care. The odds of treatment
completion were lower among adult clients with 8 to 11 years of education but with no high
school degree, those whose primary expected source of referral was not the criminal justice
system, and those whose primary source of payment was the criminal justice system compared
with high school graduates, clients whose primary source of referral was the criminal justice
system, and those whose primary expected source of payment was private health insurance. The
odds of completing treatment were 3 times higher among adult clients discharged from

80
Table 6.4 Length of Stay (LOS), in Days, among Female Substance Abuse Treatment
Clients Aged 18 or Older at Admission, by Facility Clientele Composition and
Facility Type of Care
Facility Clientele Composition
Women-Only Facilities Mixed-Gender Facilities
Average LOS Number of Average LOS
Facility Type of Care Number of Clients (in Days) Women (in Days)
Outpatient nonmethadone 2,484 295.5 245,123 152.4
1
Nonhospital residential 13,956 83.1 58,369 22.3
2
Combination 1,454 51.9 146,522 147.7
1
Difference between estimate for clients at women-only facilities and estimate for women at mixed-gender
facilities is statistically significant at the 0.01 level.
2
Difference between estimate for clients at women-only facilities and estimate for women at mixed-gender
facilities is statistically significant at the 0.05 level.

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase I data
(1996–1997) and Phase II data (1997–1999).

Table 6.5 Completion of Planned Treatment among Female Substance Abuse Treatment
Clients Aged 18 or Older at Admission, by Availability of Child Care Services
and Facility Type of Care
Child Care Services Offered Child Care Services Not Offered
Number of Women Number of Women
Completing Planned Completing Planned
Facility Type of Care Treatment Percent Treatment Percent
Outpatient nonmethadone 33,461 45.4 77,216 46.3
Nonhospital residential 454 26.4 42,349 61.3
Combination 11,819 43.1 68,382 67.5
Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phases I and II data,
1996–1999.

nonhospital residential facilities than among adult clients discharged from outpatient
nonmethadone facilities.

Receiving treatment at women-only facilities or at those offering child care services was
not associated with treatment completion among women, after controlling for other client and
facility characteristics (Table 6.8). Some control variables were associated with treatment
completion among women. Women from minority racial groups, women whose primary source
of referral to treatment was not the criminal justice system, and women whose presenting
substance abuse problem was drug abuse only were less likely to complete treatment than were
white women, women whose primary source of referral was the criminal justice system, and
women whose presenting substance abuse problem was alcohol abuse only. Unexpectedly,
women at facilities offering combined substance abuse treatment and mental health services were
less likely to complete treatment than were women receiving treatment at facilities not offering

81
Table 6.6 Length of Stay (LOS), in Days, among Female Substance Abuse Treatment
Clients Aged 18 or Older at Admission, by Availability of Child Care Services
and Facility Type of Care
Child Care Services Offered No Child Care Services Offered
Number of Average LOS Number of Average LOS
Facility Type of Care Women (in Days) Women (in Days)
Outpatient nonmethadone 76,348 168.4 171,259 147.3
1
Nonhospital residential 1,719 96.7 70,606 32.5
Outpatient methadone 3,731 386.8 32,538 548.0
Combination 41,069 353.0 106,906 67.5
1
Difference between estimate for women at facilities offering child care services and estimate for women at
facilities not offering child care services is statistically significant at the 0.01 level.

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase I data
(1996–1997) and Phase II data (1997–1999).

combined substance abuse treatment and mental health services, although this result may reflect
the larger proportion of clients with co-occurring substance abuse and mental health disorders at
facilities offering combined substance abuse treatment and mental health services. Women
receiving treatment at nonhospital residential or combination facilities were more likely to
complete planned treatment than were women receiving treatment at outpatient nonmethadone
facilities. Women receiving treatment at facilities offering prenatal care services were also more
likely to complete treatment than were women receiving treatment at facilities not offering
prenatal care services.

Survival Analysis Models

Gender was not associated with LOS, after controlling for other client and facility
characteristics (Table 6.9). Some control variables were significantly associated with LOS among
adult clients. Adult clients whose source of referral for treatment was not the criminal justice
system were more likely to leave treatment earlier than were clients whose referral source was
the criminal justice system. Adult clients discharged from nonhospital residential or combination
facilities also were more likely to leave treatment earlier than were adult clients discharged from
outpatient nonmethadone facilities. Adult clients whose primary expected sources of payment
were no payment, client self-payment, or Medicare/Medicaid stayed in treatment longer than did
adult clients whose primary expected source of payment was private health insurance.

Receiving treatment at women-only facilities or facilities offering child care services was
positively associated with LOS among women, after controlling for other client or facility
characteristics (Table 6.10). Some control variables were associated with LOS. Women who did
not complete high school, women whose source of referral for treatment was not the criminal
justice system, and women at nonhospital residential or combination facilities were more likely
to leave treatment earlier than were high school graduates, women referred by the criminal justice
system, or women at outpatient nonmethadone facilities. Contrary to expectations, receiving
treatment at facilities offering prenatal care or transportation services was associated with leaving

82
Table 6.7 Adjusted Odds Ratios (ORs) of Completion of Planned Treatment among
Substance Abuse Treatment Clients Aged 18 or Older at Admission Discharged
from Nonhospital Residential Facilities, Outpatient Nonmethadone Facilities, or
Combination Facilities
Independent Variable OR (95 Percent CI)
Female Gender 1.05 (0.85, 1.31)
Age at Admission 1.01 (1.00, 1.03)
Race (compared with white)
All other races 0.82 (0.50, 1.35)
Unknown/not mentioned 1.08 (0.60, 1.92)
Education at Admission (compared with high school graduate/GED)
Fewer than 8 years 1.09 (0.51, 2.34)
8 to 11 years and less than high school graduate 0.59 (0.38, 0.93)
College/postgraduate 0.94 (0.71, 1.27)
Unknown/not mentioned 0.71 (0.31, 1.65)
Non-Criminal Justice Source of Referral for Treatment 0.34 (0.23, 0.52)
Primary Expected Source of Payment for Treatment (compared with private health
insurance, fee-for-service, or HMO/PPO/managed care)
No payment or client self-payment 0.69 (0.40, 1.19)
Medicare/Medicaid 0.59 (0.33, 1.08)
Criminal justice system 0.52 (0.27, 0.99)
Other funding 0.66 (0.32, 1.37)
Facility Type of Care (compared with outpatient nonmethadone)
Nonhospital residential 3.19 (1.71, 5.94)
Combination 1.82 (0.80, 4.12)
CI = confidence interval; GED = general equivalency diploma; HMO = health maintenance organization; OR =
odds ratio; PPO = preferred provider organization.

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase I data
(1996–1997) and Phase II data (1997–1999).

83
Table 6.8 Adjusted Odds Ratios (ORs) of Completion of Planned Treatment among
Female Substance Abuse Treatment Clients Aged 18 or Older at Admission
Discharged from Nonhospital Residential Facilities, Outpatient Nonmethadone
Facilities, or Combination Facilities
Independent Variable OR (95 Percent CI)
Women-Only Facilities 0.76 (0.25, 2.38)
Child Care Services Offered 0.74 (0.25, 2.19)
Age at Admission 1.04 (1.00, 1.08)
Race (compared with white)
All other races 0.45 (0.22, 0.92)
Unknown/not mentioned 0.60 (0.27, 1.33)
Education at Admission (compared with high school graduate/GED)
Fewer than 8 years 0.36 (0.02, 8.35)
8 to 11 years and less than high school graduate 0.57 (0.21, 1.54)
College/postgraduate 0.87 (0.46, 1.63)
Unknown/not mentioned 1.84 (0.29, 11.62)
Non-Criminal Justice Source of Referral for Treatment 0.29 (0.09, 0.95)
Primary Expected Source of Payment for Treatment (compared with private health
insurance, fee-for-service, or HMO/PPO/managed care)
No payment or client self-payment 0.87 (0.24, 3.14)
Medicare/Medicaid 0.84 (0.30, 2.31)
Criminal justice system 0.71 (0.09, 5.64)
Other public funding 1.35 (0.39, 4.66)
Married/Common Law at Admission 0.90 (0.44, 1.82)
Have a Child/Children at Admission (compared with no child/children)
Have child/children 0.81 (0.33, 1.99)
Unknown/not mentioned 2.87 (0.89, 9.29)
Facility Type of Care (compared with outpatient nonmethadone)
Nonhospital residential 3.31 (1.12, 9.78)
Combination 3.65 (1.14, 11.67)
Presenting Substance Abuse Problem at Admission (compared with alcohol abuse only)
Drug abuse only 0.47 (0.23, 0.97)
Alcohol and drug abuse 0.72 (0.26, 2.01)
Substance not specified 2.07 (0.43, 10.00)
Prenatal Care Services Offered 3.65 (1.51, 8.84)
Transportation Services Offered 0.68 (0.30, 1.52)
Combined Substance Abuse Treatment and Mental Health Services Offered 0.37 (0.15, 0.90)
Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase I data
(1996–1997) and Phase II data (1997–1999).

84
Table 6.9 Adjusted Hazard Ratios (HRs) of Length of Stay (LOS) among Substance
Abuse Treatment Clients Aged 18 or Older at Admission Discharged from
Nonhospital Residential Facilities, Outpatient Nonmethadone Facilities, or
Combination Facilities
Independent Variable HR (95 Percent CI)
Male Gender 1.02 (0.88, 1.18)
Age at Admission 1.00 (0.99, 1.00)
Race (compared with white)
All other races 0.93 (0.77, 1.12)
Unknown/not mentioned 0.91 (0.75, 1.09)
Education at Admission (compared with high school graduate/GED or more)
Less than high school graduate 1.02 (0.90, 1.16)
Unknown/not mentioned 0.82 (0.58, 1.15)
Non-Criminal Justice Source of Referral for Treatment 1.29 (1.06, 1.58)
Primary Expected Source of Payment for Treatment (compared with private health
insurance, fee-for-service, or HMO/PPO/managed care)
No payment or client self-payment 0.64 (0.49, 0.83)
Medicare/Medicaid 0.64 (0.47, 0.87)
Criminal justice system 0.72 (0.51, 1.01)
Other funding 0.66 (0.47, 0.93)
Facility Type of Care (compared with outpatient nonmethadone)
Nonhospital residential 2.38 (1.59, 3.57)
Combination 1.94 (1.33, 2.82)
CI = confidence interval; GED = general equivalency diploma; HMO = health maintenance organization; HR =
hazard ratio; PPO = preferred provider organization

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase I data
(1996–1997) and Phase II data (1997–1999).

85
Table 6.10 Adjusted Hazard Ratios (HRs) of Length of Stay (LOS) among Female
Substance Abuse Treatment Clients Aged 18 or Older at Admission
Discharged from Nonhospital Residential Facilities, Outpatient
Nonmethadone Facilities, or Combination Facilities
Independent Variable HR (95 Percent CI)
Women-Only Facilities 0.34 (0.13, 0.89)
Child Care Services Offered 0.51 (0.36, 0.73)
Age at Admission 1.00 (0.99, 1.01)
Race (compared with white)
All other races 0.97 (0.71, 1.33)
Unknown/not mentioned 1.26 (0.89, 1.77)
Education at Admission (compared with high school graduate/GED or more)
Less than high school graduate 1.32 (1.07, 1.63)
Unknown/not mentioned 0.95 (0.65, 1.39)
Non-Criminal Justice Source of Referral for Treatment 1.32 (1.02, 1.70)
Primary Expected Source of Payment for Treatment (compared with private health
insurance, fee-for-service, or HMO/PPO/managed care)
No payment or client self-payment 0.67 (0.46, 0.97)
Medicare/Medicaid 0.54 (0.38, 0.78)
Criminal justice system 0.51 (0.31, 0.83)
Other funding 0.74 (0.47, 1.17)
Married/Common Law at Admission 1.11 (0.87, 1.42)
Have a Child/Children at Admission (compared with no child/children)
Unknown/not mentioned 1.15 (0.74, 1.78)
Have child/children 0.83 (0.63, 1.09)
Presenting Substance Abuse Problem at Admission (compared with alcohol abuse
only)
Drug abuse only 0.83 (0.65, 1.04)
Alcohol and drug abuse 0.77 (0.60, 1.00)
Substance not specified 0.51 (0.26, 0.98)
Facility Type of Care (compared with outpatient nonmethadone)
Nonhospital residential 4.39 (2.62, 7.35)
Combination 2.65 (1.84, 3.82)
Prenatal Care Services Offered 1.48 (1.09, 2.02)
Transportation Services Offered 1.61 (1.11, 2.34)
Combined Substance Abuse Treatment and Mental Health Services Offered 0.61 (0.47, 0.80)
CI = confidence interval; GED = general equivalency diploma; HMO = health maintenance organization; HR =
hazards ratio; PPO = preferred provider organization.

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase I data
(1996–1997) and Phase II data (1997–1999).

86
treatment earlier among women. Women whose primary expected source of payment was no
payment, client self-payment, Medicare/Medicaid, or the criminal justice system stayed in
treatment longer than did women whose payment source was private health insurance. Women at
facilities offering combined substance abuse treatment and mental health services also stayed in
treatment longer than did women at facilities not offering combined substance abuse treatment
and mental health services.

Summary

Descriptive analyses presented in this chapter suggested that

! women were less likely than men to complete treatment at outpatient

nonmethadone or nonhospital residential facilities,

! women were more likely than men to complete treatment in facilities offering a
combination of types of care, and

! women averaged shorter stays in treatment than men in nonhospital residential

facilities.

However, gender was not associated with completion of planned treatment or LOS in treatment,
after controlling for a number of client and organizational characteristics. In addition, receipt of
treatment at women-only facilities and at facilities offering child care services was not associated
with completion of planned treatment among women, after controlling for other client and
organizational characteristics, but both components of substance abuse treatment programming
for women were associated with longer stays in treatment. It is likely that for women, treatment
programming that specifically targets their needs is an important contributor to the positive
treatment outcomes associated with increased levels of services.

87
88
 Chapter 7. Conclusions and Implications
Female substance abusers have a distinct set of issues that suggest the need for substance
abuse treatment programming for women. Gender differences in substance abuse treatment
barriers, utilization, and retention, as well as substance use epidemiology, social context,
etiology, and physiological consequences, point to disadvantages for women. Substance abuse
treatment programming for women may include such services as child care, transportation,
prenatal care, woman-focused HIV risk reduction and mental health services, and women-only
programs that create a treatment environment focused on women’s issues.

This report extends our knowledge by providing information on factors that may impact
substance abuse treatment retention among women. Valuable new information is provided on the
effectiveness of substance abuse treatment programming for women, gender differences among
substance abuse treatment clients, availability of substance abuse treatment programming for
women, and the extent to which programming for women is associated with treatment retention.
The findings are from analyses of nationally representative data on substance abuse treatment
facilities and clients. These data from the Alcohol and Drug Services Study (ADSS) enable
consideration of treatment services across the broad range of settings in which substance abuse
treatment is delivered, as well as among diverse treatment clients in programs nationwide.

This chapter explores the implications of these findings in key areas for policymakers, the
treatment community, and researchers.

Availability and Effectiveness of Substance Abuse Treatment Programming

for Women

Chapter 2 explored the prior research on availability and effectiveness of substance abuse
treatment programming for women. Few sources of data about availability were identified.
Literature reviewed identified experimental research that showed that child care services
increased length of stay (LOS) among women, particularly in residential treatment (Hughes et al.,
1995). Women-only treatment decreased substance use and improved employment outcomes
(Dahlgren & Willander, 1989). Mental health services also increased LOS and reduced substance
use and HIV risk behaviors (O’Neill et al., 1996), prenatal care services improved birth outcomes
among pregnant women (Carroll, Chang, Behr, Clinton, & Kosten, 1995; Elk, Mangus, Rhoades,
Andres, & Grabowski, 1998), and supplemental education sessions improved attitudes about
safer sex and increased self-esteem (Hiller, Rowan-Szal, Bartholomew, & Simpson, 1996;
Volpicelli, Markman, Monterosso, Filing, & O’Brien, 2000).

Chapter 5 examined ADSS data about the availability of components of substance abuse
treatment programming for women and reported that outpatient methadone facilities were least
likely to offer child care services, even though this type of care serves the greatest proportion of
female substance abuse treatment clients. Analyses also showed that components of substance
abuse treatment programming for women are available in a minority of treatment facilities.
Women-only facilities and child care services were associated with increased LOS (but not with
treatment completion) among women (Chapter 6). Facilities treating women only served a higher
proportion of black clients than mixed-gender facilities, and facilities offering child care services

89
served a higher proportion of female clients and clients whose treatment was paid for by
Medicaid (an indicator of poverty) than did facilities not offering child care services.

Implications for Service Delivery

Findings suggest that incorporating components of substance abuse treatment

programming for women into standard care is beneficial for women and their children. Women-
only facilities may need to expand their orientation from gender-focused to culturally competent
(Trepper, Nelson, McCollum, & McAvoy, 1997) to tap into strengths in the African-American
community that may help their clients (Hill, 1993). Such strengths may include peer sources of
community/social support (Eng & Young, 1992), religiosity and faith-based leadership (Holt,
Lewellyn, & Rathweg, 2005), extended family networks (Dilworth-Anderson, 1992), and
authoritarian parenting styles that benefit children (Taylor, Chatters, Tucker, & Lewis, 1990).

Staff at substance abuse treatment facilities may require knowledge of different cultural
perspectives and skills to use in cross-cultural situations (Brach & Fraser, 2000). This knowledge
may be gained in a variety of ways, such as training clinical staff on how to work with different
racial and ethnic groups, recruiting clinical staff of the same race and ethnic identity as clients,
and using community health workers for outreach and health promotion activities (Campbell &
Alexander, 2002 ; Howard, 2003). Tailoring treatment programs to meet special needs of certain
population subgroups not only makes treatment more attractive to those who need it, but also
helps to address many of the logistical and pragmatic barriers to treatment faced by special
populations (Weiss, Kung, & Pearson, 2003).

Variability in services offered in addition to child care across facilities may contribute to
positive treatment outcomes for women. Facilities offering child care services were more likely to
be larger facilities and to offer prenatal care services; transportation services; and special
programs for women, pregnant women, dual-diagnosis clients, and AIDS/HIV-positive clients
than were facilities that did not offer child care services. Although analyses of retention in
Chapter 6 controlled for some of these organizational characteristics, effectiveness of child care
services should be examined in controlled studies to isolate the specific effects of child care over
and above benefits of other components of substance abuse treatment programming.

Implications for Treatment Access

Outpatient methadone facilities may need to explore creative arrangements to increase

access to child care services for the women they serve (through vouchers, subsidies, on-site drop-
in care, or other mechanisms). Even among types of care that more frequently offer child care
services, the quantity and accessibility of these services was not measured. In-depth study is
needed to explore whether female clients with children who need care actually receive the services
offered by facilities, versus limited numbers of child care slots prohibiting these women from
receiving timely and appropriate child care services to facilitate their entry into and retention in
treatment. In addition, research is needed to determine whether child care services in settings such
as outpatient methadone treatment are beneficial for women, since prior research has concentrated
primarily on women in residential treatment being allowed to bring their children into treatment
with them.

90
 Poor, minority women may be the primary targets of substance abuse treatment
programming for women. Thus, policymakers may want to create financing systems to encourage
the development, expansion, or improvement of substance abuse treatment programming for
women in order to reduce health disparities. Service delivery providers should also acknowledge
and address barriers and stressors experienced by African Americans, including discrimination
(Collins et al., 2000), single-parent households (Graefe & Lichter, 2002; Lane et al., 2004),
socioeconomic stressors (Murry, Brown, Brody, Cutrona, & Simons, 2001), neighborhood
environments (Williams & Jackson, 2005), and mistrust of medical or government systems
(Gamble, 1997). Recognizing the diversity of clients at women-only substance abuse treatment
facilities also is important because diversity in health beliefs and attitudes about substance abuse
and treatment may affect the utilization of services (Levi & Easley, 1999). Programs that employ
culturally appropriate frameworks can help substance-abusing minority women enter into
treatment programs and remain in recovery (Lewis, 2004).

Although such approaches as women-only treatment, child care services, and other
components of substance abuse treatment programming for women may help to increase access to
treatment for women, in-depth study is needed to explore whether high-risk female clients with
more severe substance use disorder–related problems are receiving the intensity of care they need.
Better information about severity of substance abuse and actual services received is necessary to
understand the impact of substance abuse treatment programming for women on treatment access,
retention, and outcomes in field settings. It is also important to note that other treatment services
and behavioral interventions not considered here may improve treatment retention and
longer-range treatment outcomes (McLellan & McKay, 1998), including the provision of case
management (Wechsberg, 1995), education and employment training (Etheridge, Hubbard,
Anderson, Craddock, & Flynn, 1997), and comprehensive mental health services (Grella, 1997).
In addition, research is needed to identify potential moderators of effectiveness, such as facility
size, client characteristics, or quality of family and social support resources. Research also needs
to evaluate costs in relation to benefits and effectiveness of women-only treatment or child care
services.

Implications for Treatment Providers

Women-only facilities and child care services can be crucial investments for providers in
achieving critical measures of success. However, at the provider level, if provider organizations
grow larger and more centralized to capture economies of scale, it is possible that they may not be
able to fill an adequate number of treatment slots if they serve women only. It is possible that
larger facilities may need to offer women-only programming within their mixed-gender venue, for
example, by offering women-only units, programs, workshops, or groups. The effectiveness and
implementation of such arrangements would require further study. Conversely, costs of providing
other components of substance abuse treatment programming for women, such as child care or
other services, may be prohibitive for smaller facilities with lower levels of funding. Policymakers
and providers might explore the feasibility and benefits of adding such services to existing
treatment programming.

91
Gender Differences in Substance Abuse Treatment Client Characteristics

Chapter 4 explored in detail differences and similarities between female and male
substance abuse treatment clients. Female clients were more likely to have children at admission
than were male clients. In outpatient nonmethadone treatment, which represents the largest
proportion of substance abuse treatment clients, females were less likely than males to be
employed full-time. Within this service type, females were more likely than males to live with
children but no other adult(s) at admission, to be referred to treatment by a welfare office or other
social service agencies, to use Medicaid to pay for treatment, and to be admitted for drug abuse
only.

Implications for Treatment of Specific Populations

Providers and policymakers may be in a position to support fragile families by considering

women substance abusers’ roles as primary caretakers of children. Child care services, parenting
education and support, home visiting, and mentoring are important for addressing state policies
regarding preservation and reunification of families while ensuring children’s safety and well-
being as women seek and receive substance abuse treatment and aftercare (Chaffin, Bonner, &
Hill, 2001; Gruber, Fleetwood, & Herring, 2001; Miller, Fox, & Garcia-Beckwith, 1999).
Furthermore, because socioeconomic status among women is a potential barrier to receiving and
completing treatment and maintaining sobriety, housing, educational opportunities, job training,
employment, insurance coverage, and financial planning and management are important services
for female substance abuse treatment clients (McLellan et al., 2003). With the recent welfare
reform legislation, it may be important to examine gender differences in benefits of treatment with
respect to economic and employment outcomes (Grella, Scott, & Foss, 2005; Luchansky, Brown,
Longhi, Stark, & Krupski, 2000; Oggins, Guydish, & Delucchi, 2001). Research also is needed to
identify barriers for women entering treatment-based vocational training and job counseling to
understand how women with substance use disorders fare in employment programs (Gutman,
McKay, Ketterlinus, & McLellan, 2003).

Treatment Retention among Women

In Chapter 6, descriptive and multivariate analyses yielded different results regarding the
roles of gender and substance abuse treatment programming for women in treatment retention.
Descriptive analyses showed that women were less likely to complete planned treatment and
averaged shorter stays in treatment than men in residential treatment facilities, despite the greater
availability of women-only treatment and child care services in this type of care (Chapter 5).
However, despite numerous treatment barriers among women, as cited in previous literature,
multivariate analyses showed that gender was not associated with retention.

Implications for Treatment Outcomes

Because retention, and especially LOS, is related to long-term treatment outcomes

(sobriety, employment, criminality, sex risk behaviors, family preservation, etc.), the lower
completion rate and shorter average stay for women in residential treatment may be a cause for
concern. Residential treatment settings typically admit patients with greater addiction severity

92
than outpatient facilities. Due to the lack of consistent findings in this study and existing
substance abuse treatment literature, more research is needed on gender differences in all types,
stages, and levels of care. In future studies of retention disparities, special attention should be
given to how gender interacts with drug use severity.

Issues in Women’s Substance Abuse Treatment Research

As noted in Chapter 2, much of the research reported upon in the literature has relied on
analyses of small, nonrepresentative samples. Large-scale data collection efforts, such as ADSS,
have made strides in improving the data available to researchers. However, these data pose
challenges as well.

Chapter 3 noted that many ADSS measures of programming were not defined or
standardized, and services were reported as offered, but actual exposure, receipt, and intensity of
services were not measured. An important limitation of the analyses in this report is that they are
based on cross-sectional data; thus, they represent a single snapshot in time and cannot capture the
dynamic nature of treatment service programming and utilization. Also, cross-sectional data do
not allow for causal inferences (e.g., that women-only treatment or child care services cause
longer stays in treatment). Thus, confounding factors linked to client characteristics, facility
characteristics, and retention may explain findings. Although multivariate analyses controlled for
many client and facility characteristics, data on the level of treatment need and care received were
not considered. Another limitation of the analyses is that missing information about mental illness
and pregnancy prevented examination of benefits among women with co-occurrence or among
pregnant women.

Few studies have examined the reliability and validity or overall quality of facility
administrator reports of facility size, characteristics of client populations, costs and revenues, and
other facility characteristics through reinterview techniques or checking against other documents
and collateral sources. However, as part of ADSS, investigators conducted a detailed audit of
administrator reports of client populations and cost data (Office of Applied Studies [OAS], 2003).
They found original administrator reports on client admissions to be less in need of revision than
were data on average LOS, costs, and revenues. These data considerations suggest the need for
closely controlled data collections on both client and facility characteristics, along with validation
of client and administrator reports and other data.

Although ADSS used a structured client record abstraction data collection instrument, the
quality and quantity of data collected by programs are highly variable. Records data often
underreport drug and alcohol abuse and dependence, and some services may not be recorded if
they are not reimbursed on a unit basis (Garnick, Hodgkin, & Horgan, 2002). The data are
potentially not as rich as client interview data, are often incomplete, and vary considerably in
quality and content across programs. However, client record abstracts may yield more accurate
information about sensitive behaviors than do self-reports, which are subject to considerable bias
and potential under-reporting (Harrison & Hughes, 1997). Collecting data from client record
abstracts rather than from personal interviews also decreases the considerable costs and research
burden to clients, as well as the problems associated with recall.

93
Implications for Future Research

Because performance-based programming is a priority at the national and State levels,

more detailed service and cost information will be needed. The use of uniform client assessment
procedures, as well as the development of management information systems, will enhance
performance monitoring. Standardized measures of special programming for women are necessary
for future research endeavors. More research also is needed to establish causal relationships
between programming, retention, and longer-term outcomes. Specific analyses of especially
vulnerable populations are needed, including women with co-occurring mental illness and
substance use disorders, pregnant women, HIV-positive women, impoverished women, those with
more than one child, domestic violence and child maltreatment victims, immigrants, and other
disenfranchised racial/ethnic subgroups.

Conclusions

Substance abuse treatment programming for women is increasingly available but has not
been adequately studied. This report has presented new research that helps to fill this gap. It gives
policymakers and service providers at the Federal, State, and local levels a better understanding of
why substance abuse treatment programming for women is needed, who has access to it, and
needs of female clients that are unique from needs of male clients.

Several overarching conclusions emerge from the findings presented. Substance abuse
treatment programming for women is beneficial for women and their children. Availability of
such programming appears to be limited, despite positive associations with LOS in treatment. In
multivariate analyses, gender was not associated with retention.

On the other hand, important differences between men and women were identified in
descriptive analyses. Women in residential facilities exhibited lower levels of retention than men.
In all types of care, female clients were more likely to have children at admission than males. In
outpatient nonmethadone treatment, females exhibited lower levels of socioeconomic status than
did males.

High-risk populations (women who are homeless, mentally ill, HIV positive, or violence
victims) may need more intensive and specialized services. For example, a small pilot study in
South Carolina found that rural HIV-positive women benefitted from a peer counseling
intervention to help them access and begin substance abuse treatment (Boyd et al., 2005). Women
with substance use and mental disorders may experience additional economic, social, and health
problems that may adversely affect their ability to access and remain in treatment. However,
providing treatment services to these vulnerable populations presents a difficult challenge to
treatment providers because of the intensive, lengthy treatment required.

Large national datasets, such as ADSS, are available for additional study. Such datasets
provide policymakers and researchers with an important base from which to study substance
abusing populations and the systems providing services to these populations. A key implication of
this report’s analyses is that improvement of quality of data could come from standardizing and

94
defining measures. Clear definitions are needed for assessing clients and for defining the types of
services they receive.

Managed care for substance abuse treatment services has shifted treatment from inpatient
to outpatient treatment settings, thus bringing focus to outpatient nonmethadone and outpatient
methadone facilities as settings where large proportion of women are served. Health economics
research is needed to conduct cost analyses in these two settings. More detailed information about
women, women’s services, and retention in these settings also is needed.

Although more research is needed to determine causality of associations and to examine

special populations of women, this report clearly shows that women in substance abuse treatment
have needs that are unique and that components of substance abuse treatment programming are
positively linked with treatment retention, after controlling for many potential confounders. It is
hoped that the research presented here will help to inspire increased and improved policies and
services and new research that will continue to improve the lives of women and their children.

95
References

Boyd, M. R., Moneyham, L., Murdaugh, C., Phillips, K. D., Tavakoli, A., Jackwon, K., Jackson,
N., & Vyavaharkar, M. (2005). A peer-based substance abuse intervention for HIV+ rural women:
A pilot study. Archives of Psychiatric Nursing, 19(1), 10-17.

Brach, C., & Fraser, I. (2000). Can cultural competency reduce racial and ethnic health
disparities? A review and conceptual model. Medical Care Research Review, 57 Suppl 1,181-217.

Campbell, C. I., & Alexander, J. A. (2002). Culturally competent treatment practices and ancillary
service use in outpatient substance abuse treatment. Journal of Substance Abuse Treatment, 22,
109-119.

Carroll, K. M., Chang, G., Behr, H., Clinton, B., & Kosten, T. R. (1995). Improving treatment
outcome in pregnant, methadone-maintained women: Results from a randomized clinical trial.
American Journal on Addictions, 4, 56-59.

Chaffin, M., Bonner, B. L., & Hill, R. F. (2001). Family preservation and family support
programs: Child maltreatment outcomes across client risk levels and program types. Child Abuse
& Neglect, 25, 1269-1289.

Collins, J. W. Jr., David, R. J., Symons, R., Handler, A., Wall, S. N., & Dwyer, L. (2000).
Low-income African-American mothers’ perception of exposure to racial discrimination and
infant birth weight. Epidemiology, 11, 337-339.

Dahlgren, L., & Willander, A. (1989). Are special treatment facilities for female alcoholics
needed? A controlled 2-year follow-up study from a specialized female unit (EWA) versus a
mixed male/female treatment facility. Alcoholism, Clinical and Experimental Research, 13,
499-504.

Dilworth-Anderson, P. (1992). Extended kin networks in black families. Generations, 16(3),

29-32.

Elk, R., Mangus, L., Rhoades, H., Andres, R., & Grabowski, J. (1998). Cessation of cocaine use
during pregnancy: Effects of contingency management interventions on maintaining abstinence
and complying with prenatal care. Addictive Behaviors, 23(1), 57-64.

Eng, E., & Young, R. (1992). Lay health advisors as community change agents. Family and
Community Health, 15, 24-40.

Etheridge, R. M., Hubbard, R. L., Anderson, J., Craddock, S. G., & Flynn, P. M. (1997).
Treatment structure and program services in the Drug Abuse Treatment Outcome Study
(DATOS). Psychology of Addictive Behaviors, 11, 244-260.

Gamble, V. N. (1997). Under the shadow of Tuskegee: African Americans and health care.
American Journal of Public Health, 87, 1773-1778.

96
Garnick, D. W., Hodgkin, D., & Horgan, C. M. (2002). Selecting data sources for substance abuse
services research. Journal of Substance Abuse Treatment, 22, 11-22.

Graefe, D. R., & Lichter, D. T. (2002). Marriage among unwed mothers: Whites, blacks, and
Hispanics compared. Perspectives on Sexual and Reproductive Health, 34, 286-293.

Grella, C. E. (1997). Services for perinatal women with substance abuse and mental health
disorders: The unmet need. Journal of Psychoactive Drugs, 29, 67-78.

Grella, C. E., Scott, C. K., & Foss, M. A. (2005). Gender differences in long-term drug treatment
outcomes in Chicago PETS. Journal of Substance Abuse Treatment, 28 Suppl 1, S3-S12.

Gruber, K. J., Fleetwood, T. W., & Herring, M. W. (2001). In-home continuing care services for
substance-affected families: The bridges program. Social Work, 46, 267–277.

Gutman, M. A., McKay, J., Ketterlinus, R. D., & McLellan, A. T. (2003). Potential barriers to
work for substance-abusing women on welfare. Findings from the CASAWORKS for Families
pilot demonstration. Evaluation Review, 27, 681-706.

Harrison, L., & Hughes, A. (Eds.). (1997). The validity of self-reported drug use: Improving the
accuracy of survey estimates (NIH Publication No. 97-4147, NIDA Research Monograph 167).
Rockville, MD: National Institute on Drug Abuse. [Available as a PDF at
http://www.drugabuse.gov/pdf/monographs/monograph167/download.html]

Hill, R. B. (1993). Dispelling myths and building on strengths: Supporting African American
families. Accessed August 11, 2005, from http://www.nysccc.org/T-Rarts/DispelMyths.html

Hiller, M. L., Rowan-Szal, G. A., Bartholomew, N. G., & Simpson, D. D. (1996). Effectiveness of
a specialized women’s intervention in a residential treatment program. Substance Use & Misuse,
31, 771-783.

Holt, C. L., Lewellyn, L. A., & Rathweg, M. J. (2005). Exploring religion-health mediators among
African American parishioners. Journal of Health Psychology, 10, 511-527.

Howard, D.L. (2003). Culturally competent treatment of African American clients among a
national sample of outpatient substance abuse treatment units. Journal of Substance Abuse
Treatment, 24(2), 89-102.

Hughes, P. H., Coletti, S. D., Neri, R. L., Urmann, C. F., Stahl, S., Sicilian, D. M., & Anthony, J.
C. (1995). Retaining cocaine-abusing women in a therapeutic community: The effect of a child
live-in program. American Journal of Public Health, 85, 1149-1152.

Lane, S. D., Keefe, R. H., Rubinstein, R. A., Levandowski, B. A., Freedman, M., Rosenthal, A.,
Cibula, D. A., & Czerwinski, M. (2004). Marriage promotion and missing men: African American
women in a demographic double bind. Medical Anthropology Quarterly, 18, 405-428.

97
Levi, D. B., & Easley, C. (1999). African American women and substance abuse: An overview.
Journal of Cultural Diversity, 6(3), 102-106.

Lewis, L.M. (2004). Culturally appropriate substance abuse treatment for parenting African
American women. Issues in Mental Health Nursing, 25, 451-472.

Luchansky, B., Brown, M., Longhi, D., Stark, K., & Krupski, A. (2000). Chemical dependency
treatment and employment outcomes: results from the ‘ADATSA’ program in Washington State.
Drug and Alcohol Dependence, 60, 151-159.

McLellan, A.T., Gutman, M., Lynch, K., McKay, J.R., Ketterlinus, R., Morgenstern, J., & Woolis,
D. (2003). One-year outcomes from the CASAWORKS for Families intervention for substance-
abusing women on welfare. Evaluation Review, 27, 656-680.

McLellan, A. T., & McKay, J. R. (1998). The treatment of addiction: What can research offer
practice? [Commissioned Paper, Appendix D]. In S. Lamb, M. R. Greenlick, & D. McCarty
(Eds.), Bridging the gap between practice and research: Forging partnerships with
community-based drug and alcohol treatment (pp. 147-185). Washington, DC: National Academy
Press. [Available at http://books.nap.edu/catalog/6169.html]

Miller, B. V., Fox, B. R., & Garcia-Beckwith, L. (1999). Intervening in severe physical child
abuse cases: Mental health, legal, and social services. Child Abuse & Neglect, 23, 905-914.

Murry, V. M., Brown, P. A., Brody, G. H., Cutrona, C. E., & Simons, R. L. (2001). Racial
discrimination as a moderator of the links among stress, maternal psychological functioning, and
family relationships. Journal of Marriage and Family, 63, 915-926.

Office of Applied Studies. (2003). Alcohol and Drug Services Study (ADSS) cost study: Costs of
substance abuse treatment in the specialty sector (DHHS Publication No. SMA 03-3762, Analytic
Series A-20). Rockville, MD: Substance Abuse and Mental Health Services Administration.
[Available at http://www.oas.samhsa.gov/analytic.htm and http://www.oas.samhsa.gov/adss.htm]

Oggins, J., Guydish, J., & Delucchi, K. (2001). Gender differences in income after substance
abuse treatment. Journal of Substance Abuse Treatment, 20, 215-224.

O’Neill, K., Baker, A., Cooke, M., Collins, E., Heather, N., & Wodak, A. (1996). Evaluation of a
cognitive-behavioural intervention for pregnant injecting drug users at risk of HIV infection.
Addiction, 91, 1115-1125.

Taylor, R. J., Chatters, L. M., Tucker, M. B., & Lewis, E. (1990). Developments in research on
Black families: A decade review. Journal of Marriage and the Family, 52, 993-1014.

Trepper, T. S., Nelson, T. S., McCollum, E. E., & McAvoy, P. (1997). Improving substance abuse
service delivery to Hispanic women through increased cultural competencies: A qualitative study.
Journal of Substance Abuse Treatment, 14, 225-234.

98
Volpicelli, J. R., Markman, I., Monterosso, J., Filing, J., & O’Brien, C. P. (2000). Psychosocially
enhanced treatment for cocaine-dependent mothers: Evidence of efficacy. Journal of Substance
Abuse Treatment, 18, 41-49.

Wechsberg, W. M. (1995). Strategies for working with female substance abusers. In B. Brown
(Ed.), Substance abuse treatment in the era of AIDS (pp. 119-152). Rockville, MD: Center for
Substance Abuse Treatment.

Weiss, S. R., Kung, H. G., & Pearson, J. L. (2003). Emerging issues in gender and ethnic
differences in substance abuse and treatment. Current Women’s Health Reports, 3, 245-253.

Williams, D. R., & Jackson, P. B. (2005). Social sources of racial disparities in health. Health
Affairs, 24, 325-334.

99
100
 Appendix: Statistical Methods and Limitations of the Data
This section describes detailed analytic methodology used in the report. Additional
limitations of the data are also discussed.

Suppression Criteria for Unreliable Estimates

Minimum nominal sample size suppression criteria (n = 5) were used that protect against
unreliable estimates caused by small nominal sample sizes. To maximize reliability and minimize
the need to suppress results, variable categories generally were collapsed where unweighted cell
counts were less than 5.

National Facility Rates

For each client characteristic reported by facilities (i.e., gender, race/ethnicity, age, and
payment source) in Chapter 5, an individual facility rate was calculated by dividing the number of
active clients with each characteristic by the total number of active clients for each facility. Next,
a national facility rate for each characteristic was calculated by summing individual facility
percentages and dividing by the number of facilities with active clients reporting the characteristic
across all facilities. The prevalence of selected facility characteristics (type of care, size,
ownership, special programs, and services offered) was calculated as percentages of the number of
facilities overall.

Because of this methodology, rates discussed in this report are not strictly comparable with
percentages of clients at facilities reported by other data sources. Rates represent an average of
percentages reported by facilities, regardless of the number of clients each facility served. This
calculation underestimates the true proportions of client characteristics among sampled facilities
with large numbers of clients and overestimates the proportions among sampled facilities with
small numbers of clients. However, estimates for some client characteristics reported by facilities
are similar to those reported by other national studies of substance abuse treatment clients.

Multivariate Analyses

Treatment completion and length of stay (LOS) were modeled in a series of multivariate
analyses in Chapter 6. Variables of interest were analyzed separately and together with various
combinations of control variables. Findings were consistent across various models containing
different sets of variables, indirectly implying that the models are stable.

Because many prior studies examining retention analyzed clients separately by type of care
received, descriptive analyses in the present study were stratified by type of care. Multivariate
analyses were conducted on the full samples of adult clients or adult female clients to preserve
these large samples. Accordingly, three dummy variables were included in the models indicating
treatment at residential facilities, outpatient nonmethadone facilities, or facilities offering a
combination of types of care.

101
 Two final comprehensive models analyzed (1) treatment completion or (2) LOS as a
function of gender, controlling for facility type of care, age at admission, race, education at
admission, primary source of referral to treatment, and primary expected source of payment for
treatment. Correlations between organizational characteristics were calculated to test for
multicollinearity of variables prior to modeling and to test assumptions about relationships
between these characteristics. Although many organizational characteristics were significantly
correlated, Pearson product-moment correlation coefficients were relatively low (range = -0.09 to
0.40), indicating that multicollinearity was not an issue in the analyses. Therefore, all
organizational characteristics were included in one model for treatment completion and one model
for LOS. These additional two final comprehensive models analyzed retention as a function of
organizational characteristics of interest, controlling for facility type of care, client age at
admission, client race, client education at admission, primary source of referral for treatment,
primary expected source of payment for treatment, marital status at admission, having children at
admission, type of presenting substance abuse problem at admission, and treatment at facilities
offering prenatal care services, transportation, or combined substance abuse and mental health
treatment services.

Analyses of LOS used survival analysis (specifically, Cox’s proportional hazard regression
analysis), which considers situations in which (1) a dependent variable represents a time to a
terminal event and (2) the duration of the study is limited in time. In this analysis, the terminal
event was discharge from treatment. Survival analysis can include both censored and noncensored
observations. An observation is considered censored by the end of the study period if the terminal
event had not yet occurred or if the observation was followed up to a certain time point, after
which there was no further information on the client. ADSS provides information on the duration
of stay in treatment for all subjects from the beginning to the end of the observation period. For
the purposes of this analysis, the time of study was determined to be 3,000 days, and observations
with a longer stay in treatment than 3,000 days were considered to be censored.

In Cox’s hazard regression analysis, it is assumed that (1) a hazard function is constant
over time and (2) all deviations are random. Under the assumption that hazard function is
constant, it is possible to say that a higher hazard ratio (HR) suggests that clients in the “exposed”
group stay in treatment a shorter time than the comparison group. Fitting the models was assessed
using criteria provided in SUDAAN® Survival Analysis (RTI International, 1995) output as
follows:

1. -2*normalized Log-Likelihood with = 0.

2. -2*normalized Log-Likelihood for a full model.
3. Approximate 2 (-2Log-Likelihood Ratio).

Target Population

An important limitation of the Alcohol and Drug Services Study (ADSS) estimates of
substance abuse treatment facility and client characteristics is that they are designed only to
describe the target populations of the study: (1) active public and private substance abuse
treatment facilities and (2) clients discharged from substance abuse treatment facilities. Although
12,387 facilities and 2.2 million clients are represented by these populations, ADSS excludes
some important and unique subpopulations that may have very different characteristics. For

102
example, the Phase I survey excludes halfway houses without paid counselors, which may have
significantly different client and facility characteristics. Client records from hospital inpatient
facilities are not included in Phase II and have been shown to involve shorter stays in treatment.
Also excluded are client records from facilities in which 100 percent of clients were treated for
alcohol abuse, a population with different client characteristics and retention rates.

Screening and Interview Response Rate Patterns

The Phase I screening facility response rate was about 79 percent, and the interview
response rate was about 91 percent. Rates of nonresponse ranged from 5 percent among
nonhospital residential facilities to 12 percent among outpatient, almost exclusively alcohol
facilities.

Item Nonresponse

Among Phase I facilities, item response rates were above 98 percent for most
questionnaire items. About 80 percent of the 240 items on the facility questionnaire had less than
1 percent missing data, 15 percent (35 items) had between 1 and 10 percent missing values, and
only 5 percent (12 items) had between 20 and 25 percent nonresponse. Logical imputations,
imputations using external sources, and imputations using statistical methods were used to fill in
missing values for key variables. Statistical methods included two nondeterministic methods:
random regression (Montaquila & Ponickowski, 1995) and random within-class hot deck (Kalton
& Kish, 1984). Imputation was performed to blocks of items at a time—point-prevalence counts,
admissions, and other items. Within each block, missing totals were imputed first, followed by
imputation of missing components of the total to produce internally consistent responses.

In Phase II, several items required data that could not be ascertained from the client
discharge abstract. To address this, variables with 15 percent or more missing data for the total
sample, or 25 percent or more missing data for one of the treatment service types, were excluded
from analyses of client characteristics in Chapter 4. For example, ethnicity was not ascertained for
26 percent of the total sample and was not included in the analyses. Lifetime use of alcohol also
was not ascertained for 7 percent of the total sample, including 29 percent of females discharged
from methadone treatment, and was not included in the analyses. In addition, because 31 percent
of records for female clients discharged from outpatient nonmethadone or nonhospital residential
treatment were missing data about pregnancy at admission, planned analyses about pregnancy
could not be conducted.

Validity of Facility Administrator Reports

Estimates of the availability of substance abuse treatment programming for women in

Chapter 5 are based on facility director reports of client and facility characteristics, and their value
depends on respondents’ truthfulness and accuracy. No studies have been published to address the
validity and reliability of facility administrator reports. Director, record, and client data may be
inconsistent because program directors may have inaccurate or incomplete information about the
logistics of their programs.

103
References

Kalton, G., & Kish, L. (1984). Some efficient random imputation methods. Communication in
Statistics, 13, 1919-1939.

Montaquila, J., & Ponickowski, C. (1995). An evaluation of alternative imputation methods. In

Proceedings of the American Statistical Association, Survey Research Methods Section (pp.
281-286). Alexandria, VA: American Statistical Association.

RTI International. (1995). SUDAAN® software for analysis of correlated data: User’s manual,
Release 6.4. Research Triangle Park, NC: RTI International.

104